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n� SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> For.�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z- -6 a 1Jo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued lo_Z4e-.7-7 <br /> (Complete In Triplicate) ,J ; b S`��-Z/o -•,S2- <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 /> 576 3 - r6-f-tTr <br /> JOB ADDRESS/LOCATION , ,r T , -A/6 64 0-r is -`/6 � CENSUS TRACT <br /> Owner's Name L Lu,✓ J, ✓ Phone <br /> Address F1 , dit� City . <br /> .41 <br /> Contractor's Name A/ License # / ''Ishone _y 7t'?�, <br />- TYPE (}F WORK (Check) : NEW WELL /�/ DEEPEN RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PZ,'MP REPAIR ZLt/ PUMP REPLACEMENT 1-T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 r <br /> Other Rotary Type of Grout <br /> J <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor v k)�- to <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP U-PAIR: / (/ State Work Done �L� &,jk trh et_eA,g <br /> ,DFfiTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - - Describe Material and Procedure <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 try 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 of my kAan <br /> ge/ d~b lief. <br /> SIGNED �Lv G1.raj TLE <br /> (DT PLAN ON RE RSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> G PHASE I , <br /> APPLICATION ACCEPTED BY C DATE /d z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 'N <br /> E H 1426 - -- 5/731M <br />