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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per <br /> No. p <br /> THIS .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y/.52 <br /> �+/�,.-,-,�uSTc A.-) (Complete In Triplicate) eA-) X017 -2,Po /4, <br /> �. <br /> ~ to the San Joaquin Local Health District for a permit to construct <br /> Application is hereby made <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 gulations of the San Joaquin Local <br /> Aga `h District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> City - <br /> Address <br /> ity •Address <br /> Contractor's Nam icense # C�1 Q 'hone K�d S f <br /> _4 <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN /_T RECONDITION / / DESTRUCTION �? <br /> PUMP INSTALLATION / REPAIR / / PUMP REPLACEMENT 1_7 N <br /> Other <br /> DW. <br /> ER LIES �4—RIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWAGE DISPOSAL FIELD --7`CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI NS <br /> Industrial Cable Tool Dia. of Well Excavation s <br /> Drilled 'Dia. of Well Casing Co 5 l <br /> j �mestic/private ` Driven Gauge of Casing �-• <br /> Domestic/public � . <br /> Irrigation _Gravel Pack .- Depth of Grout Seal dz iu� <br /> Other 4---Ro—tary Type.of Grout � �fyt1 f <br /> [ Other Other Information <br /> ,, <br /> PUMP INSTALLATION: Contractor �✓ H.P. <br /> Type of Pu <br /> PUMP REPLACEMENT: / / State Work Done <br /> n <br /> PUMP REPAIR-., ,. / /_ State Work:Done-N <br /> ( ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> j and the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work well and notifyw well, Tthemlbeforesh the puttingatheowellninouse.cal HeThehaboverict. a <br /> WELL DRILLERS REPORT of the knowledge and belief. <br /> infor ion is true to the o y_ S <br /> SIGNED Q f TITL <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHA -DATE <br /> t APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT. INSPECTIO INSPECTION BY DATE <br /> INSPECTION BY ATE <br /> CALL FOR A GROUT INS ECTION :PRIOR TO GROUTING AND FINAL INSPECTION. 7172 1M <br /> ' E H 1426 1 <br />