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SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> FOR OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7GU <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued <br /> (Complete In Triplicate) f 2-ce — l 9 O <br /> Application is hereby made to the San Joaquin Local Health District f0 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 ,. "� � '� ��'~`"`s <br /> Ltr�e CENSUS TRACT <br /> Owner's Name �I_ L c"",.,�F_ !R�_._ -- Phone 'Y64r � �S 7S- <br /> Address Irl. Z262/� �tf City <br /> Contractor's Name AAA leK ,.,d. 7%a.ACR yy� a License # 7 a3 Phone y71-j4r5''4F <br /> TYPE OF WORK (Check): NEW WELL ,V DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES �y4D PIT PRIVY <br /> Q <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 t ' <br /> v Domestic/public Driven Gauge of Casing 2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 2.av C a f_ okL"nect H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,pESTRUCTION 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 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED 4 TITLE <br /> Ar <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE j4jGROUT INSPECTI0 PHASE II /FINAL INSPECTION <br /> INSPECTION BY / DATE INSPECTION BY DATE S -4 <br /> CALL FOR A GROUT INSPECTION P OR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7172 1M <br />