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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:OFFICE USE: —1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 3-o1s 7¢ <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 Joaqui: <br /> County_ Ordinance No. 1862. and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO�i ,�Jd✓ ' ��► cy � r" a A-4he444- CENSUS TRACT <br /> Owner's Name Phone <br /> r, <br /> Address ff',C� �v� //,� � -�"+#-Yrt1 1 1't_ <br /> City <br /> k <br /> Contractor's Name License # /971S�Phone .4- 2KA', <br /> Ur <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/—/ RECONDITION /—/ DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR Y PUMP REPLACEMENT <br /> Other ./ / --- <br /> DISTANCE TO NEAREST: SEPTIC THINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> 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 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump `.: H.P. 6 y <br /> x PUMP REPLACEMENT: 4 / / State Work Done <br /> 3 PUMP 'tEPATR: State Work Done 66 4-10 ��A.6� ,�„f'�° 6 , �t�` *ft <br /> Aa? DFgTRUCTION OF WELL: Well Diameter Approximate Deptih <br /> j Describe Material and Procedure <br /> i <br /> T 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 /> information is true to the best y ow edge nd belief. <br />'t SIGNED-Q- TITLE CSI' <br /> j <br /> D PLO PLAN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />^� APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMNTS: <br /> PHASE II GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r_�Q �9_� ,SG , <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E- H 1426 r 1�•,___ <br />