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N JOAQUIN LOCAL HEALTH DISTRIC" <br /> FOR OFFICE USE: j�160�. Hazelton Ave. , Stockton, Ca1�. <br /> { Telephone: (209) 466-6781 �� �7iIrw�Nu ry <br /> APPLICATION FOR WELL CONSTRUCTION OR PU >uT�Iit No. / <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 3 <br /> (Complete In Triplicate) 'T t . <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 17101 5-.r <br /> JOB ADDRESS/LOCATION /y1 �,y� (/R� �ATr / zN(/G CENSUS TRACT S �Y <br /> Owner's NamL ,IMt / Y� Lrf[.f-� _ u / —`?— <br /> d / Phone / 7 lc1 F <br /> Address Yl j L ( 'cCtY City <br /> Contractor's Name Dn�,L /V/-- License 111&� Phone r13 <br /> TYPE OF WORK (Check) : NEW WELI. /V DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-T <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 /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Y Drilled Dia. of Well Casing <br /> Domestic/public �" Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> OtherRotar Type of Grout <br /> Y YP <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. _! <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done 1—75 : � <br /> pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informationE is true to the best of my knowledge and belief. /j, <br /> SIGNED ( , , r �; [ 4, tX11, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP . TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT / r DATE Z -Z�o <br /> ADDITIONAL CO <br /> E UT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECT ON B DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M �� �� <br />