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' N0 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I'OF.:OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> V E EV Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zoe_11 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued -3,2S <br /> (Complete In Triplicate) <br /> I Application is hereby made to the San Joaquin Local Health District for a permit to .constr,uct <br /> and/or install the work herein described. * This application is made in compliance with San Jb; <br /> County Ordinance-No.. 1862-and the Rules and Regulations of the Sap Joaquin Local He.il.th DiaCr: <br /> JOB ADDRESS/LOCATIONic f gEilz,, G/ 1 Cb !& 0SUS TRACT <br /> Owner's Name A 1Z A JEn Ir;mS Phone <br /> Address C Cit <br /> Contractor's Name �� License #-279via Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_ RECONDITION /_/ DESTRUCTION <br /> 7 / <br /> AL <br /> PUMP INSTLATION J / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other./ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrials ` Cable Tool Dia. of Well Excavation <br /> Dome - Drilled Dia. of Well Casing <br /> Domestic./pu4Iic �� DrivenGauge of Casing <br /> Irrigation �o f ---� <br /> i g � Gravel Pack Depth of Grout�Seal • • - - r <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work 'Done <br /> a PUMP REPAIR: State Work Done <br /> , <br /> ' DF.TRUCTION OF WELL: Well Diameter .� Approximate Depth <br /> Describe Material and Procedure <br /> - <br /> I hereby agtae to omply-with all laws and regulations'-of the San Joaquin Local Health Distric <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAY <br /> after completion of.my work on a new well, I will furnish the San Joaquin Local Health Distric <br /> i WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true:wto the best of my knowledge and belief. <br /> i SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> ! PHASE I <br /> APPLICATION ACCEPTED .BY �� ��; DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FIN INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CAIS. VnD• A r_Dnnm Ttvenan.nTnxr TTT! ,,. ,... .,..�.._ .___ ____._ ____. <br />