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��S + SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � <br /> LOT.- <br /> USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ... Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. !j am �/o { <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date,Issued 3- /C!_74- <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 Jpaquin <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> ! <br /> JOB ADDRESS/LOCATION //� Icy �+ CENSUS TRACT <br /> L 21 <br /> Owner's Name UGC it�fe�... r _ .��. Phone <br /> Address a ev 4 Q k City <br /> Contractor's Name ,,a License # Phone <br /> TYPE OF WORK (Check): NEW WELL I I DEEPEN '/ / RECONDITIOW/ /_7/ DESTRUCTION / <br /> PUMP INSTALLATION IWI PUMP REPAIR / ­PUMP PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TkNK 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 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 /> { <br /> PUMP INSTALLATION: Contractor r.S Y-V�m2��&t-Av <br /> Type of Pump 6G a gn / H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br />€ PUMP / State Work Done 'I� dj rr,si Jab <br /> j DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure T <br /> I hereby agree to comply tri,th 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 /> 3 information is true to the,best of(--m edge d belief. Ile <br />'i SIGNED D/ CSW TITLE <br /> �µ (W nOT PLAN ON VERSE SIDE) <br /> 4. DEPARTMENT USE ONLY <br /> E PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR PidTION PHAS /FIN INSPECT 4N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> __ Zaz/z <br /> CALL FOR A GROUT IN PECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731.M r`j <br />