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F:...^.-_'•.SPI <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f O£. OFFICE USE: 160 . E. Hazelton Ave. , Stockton, Calif. S r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.✓ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .. <br /> , I (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. 1: 362 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .SOS ADDRESS/LOCATION � C p L, 4142? D A6 4s r,l� . CENSUS TRACT <br /> Owner's Name L.CO/VE ��f/�l --- Phone <br /> A <br /> Address -1,;L E3,'/ Al. Gle- L G y /z D City OP 1 CC- <br /> Contractor's <br /> CContractor's Name 414Gfior,% We L i- 0Rj4L,11V6 License #zggl2o Phone '74 S"=/d5--Z- <br /> TYPE OF.WORK (Check) ; NEW WELL 'DEEPEN / / RECONDITION / I DESTRUCTION /7 <br /> PUMP INSTALLATION /N PUMP REPAIR / / PUMP REPLACEMENT <br /> Other l / <br /> DISTANCE TO NEAREST: SEPTIC TANK /'0© ` SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE•PIT, OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION' SPECIFICATIONS C <br /> 0 <br /> Industrial _� Cable Tool Dia. of Well Excavation —1-2," � <br /> Domestic/private _ Drilled Dia. of Well Casing " <br /> Domestic/public'. _ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal D <br /> Other Rotary Type of Grout <br /> ij Other Other information <br /> PUMP INSTALLATION: Contractor . �w/s 71G f <br /> Type of Pump H.P, t <br /> PUMP REPLACEMENT: / / State Work Done <br /> G PUMP U7PAIR: / / State Work Done <br /> .DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r 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 /> I after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT `bf the well and notify them before putting the well in use. Theabove <br /> information `is true do the best of my knowledge and belief. s <br /> SIGNED _ 'E � TITLE ► . <br /> (tRAW PLOY PLAN ON REVERSE SIDE) -- <br /> �� Y FOR DEPARTMENT USE ONLY r <br /> PHASE I <br /> APPLICATION ACCEPTED 06Y DATE <br /> ADDITIONAL COMMENTS: .IM <br /> PHAS I : G QUT INSPECT N PHASE II/ AL INSPECTI N <br /> INSPECTION BY DATE ? INSPECTION Bl�—, DATE /Y <br /> -CALL-FOR--A-GROUT.-INSPECTION�PR• 0R-••TO GROUTING AND•-FINAL-INSPECTION-- <br /> E <br /> NSPECTIO .E H 1426 iM 5/731M <br />