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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�75- 3S"i/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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 land Regulations t San Joaquin Local ilealth District. <br /> zj <br /> JOB ADDRSS/ORATIONi CENSUS TRACT T(J4 _— <br /> i / <br /> Owner's Name � �(` 'a /�' � 1� \ � Phone -3("&-b� � <br /> Address /0 l/_S .�._ _...-s� ` 'Q r C� City . 1_ <br /> Contractor's Name License �EJ��Z one 7 <br /> TYPE OF WORK (Check) : NEW WELL /T DEEPEN / j RECONDITION / / DESTRUCTION /-7- <br /> PUMP INSTALLATION /—/ PIW REPAIR / —PUMP PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA14K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE _TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing /;)- _ <br /> Dom tic/public Driven Gauge of Casing _ / 0 <br /> i <br /> Dom <br /> Gravel Pack Depth of Grout Seal S---L- <br /> Other <br /> $''LOther Rotary Type of Grout cy S PIC- <br /> Other <br /> t Other Other Information <br /> PUMP INSTALLATION: Contractor LL's <br /> Type of Pump H.P. <br /> PU?fP REPLACEMENT: / / State Work Done fi <br /> PUMP `�-EPAIR: / / State Work Done <br /> DFgTRUCTION 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 /> r after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 14ELL 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 /> SIGNEDTITLE <br /> ( (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> a PHASE I <br /> APPLICATION ACCEPTED BY �/���,�„�_/ DATE /d ,a-73 <br /> ADDITIONAL COMi-fENTS: _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 7-_3 " 7j INSPECTION BY 711i�? DATE /0 - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E,H.1426 • . 5/731M <br />