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!r SAN JOAQUIN LOCAL `HEALTH DISTRICT <br /> l <br /> FO COPPICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �17 <br /> I - � <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued/ _,3 Tc <br /> (Complete. In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to consLr uct <br /> and/or install the. work herein described. - This application is made in compliance with San Joaquin <br /> County Ordinance No. 1$b2 and the RuXes and Regulations of the San Joaquin Local Health District. <br /> ,JOB ADDRESS/LOCATEON IM AA *1111 � 1 <br /> Owner's Name E /1fz2)419 -- -- - Phone <br /> Address .A.-U 6- City ' <br /> Contractor's Name _ eL� License_ n73� Phon -c� 3 . <br /> TYPE OF WORK (Check) : -NEW WELL -/T//" DEEPEN '/_/ RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP INSTLATION PUMP REPAIR '/ / PUMP REPLACEMENT ITT <br /> AL <br /> Other.1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal I1 <br /> OtherL. 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 /> PUMP UPAIR: / / State Work Done <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> G 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'FTFTEEN 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 /> information is true to the best of my knowledge and belief. <br /> i <br /> SIGNED TIT <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -� --- - <br /> FOR DEPARTMENT USE ONLY <br /> -PHASE ID .t^r.)P� �t <br /> APPLICATION ACCEP D BY � '.T [DAT_�irl ���i <br /> ADDITIONAL COQ s: <br /> P SE GROUT INSPECTION PhJWII AL INSPECTION <br /> INSPECTIO DATE ZINSPECTI DATE •- 7-7 , <br /> CALL FOR A -GROUT INSPECTION- PRIOR TO GR TING AND FINAL INSPECTION. <br /> E H 1426 5/,731X <br />