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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> r70 ..OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z_1/_-4/e9 4j, <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -2170 S CORRAL #01-1-ON n/ R I) CENSUS TRACT ' <br /> Owner's Dame 514M U CL [30 N /L Ln Phone 93S -7-370 <br /> Address '�I b S _ �4BB lL _ #O L©1N E D , City ,T�r+Gy ! <br /> A; 1 , - <br /> Contractor's Name HF_N 4i r4C J .Q ' pit-t `►N'r Cd ,-.SNC. Licensgj=_ -hone. <br /> TYPE OF WORK (Check) : NEW WELL '/V DEEPEN /_/ RECbK1 iT10N CIT DESTRUCTION ./-7 <br /> PUMP INSTALLATION / / PiIMP REPAIR /_-/ PUMP_ PLACEMENT <br /> 1_7 <br /> Other 1_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK so SEWER LINES __57D 1 PIT PRIVY its4n/C-- <br /> SEWAGE DISPOSAL FIELD CESSPOOL"/SEEPAGE PIT 66fNF—OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ::�. �� CableT©q ..Dia. of Well Excavation " <br /> x Domestic/private {f `> j Drilled ilia. of WefI Casing <br /> Domestic/public Driven 4: ge of. Casing <br /> ,.. } <br /> Irrigation t . Gravel Pack. Depth of"Grout Seal SQ <br /> Other --. --. Rotary Type of Grout <br /> { � Other Other Information ' �c Iq(3 I3.y f>WN;E <br /> --�-- - .-...- <br /> PUMP INSTALLATION: Contractor <br /> E Type of Pump H.P. <br /> PUMP REPLACEMENT: y!/ State Work Done <br /> g,�Q yvoT FjEAJ <br /> PUMP 'tEPAIR: State Work Done / <br /> i <br /> t # s <br /> ,DFCTRUCTION OF WELL:` W(M Diameter Approximate Depth P <br /> Describe Material and Procedure <br /> { <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 /> after completion of my work on a new well, I will ,furnish the San Joaquin Local Health District a� <br /> WELL DRILLERS REb <br /> PORT of .the well and notify them efore putting the well in use. The above <br /> information-is-true-to-the best.-of•.my .knowledge--and.-belief.._ <br /> SIGNED ., �(�- ,-.© -TITLE--- <br /> / (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,,5_^7 <br /> APPLICATION ACCEPTEI3� . DATE , <br /> ADDITIONAL COMMENTS. <br /> r P ROUT INSPECTION PUS <br /> wit /_XM,FNSPECirTON <br /> INSPEC ON' Y DATE !20- ZI�SPECTTON .BY DATE - <br /> CALL_ Oki,-A,GROUT INSPECTION PRIOR TOG UTING AND FINAL 114SPECTION. <br />