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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fdi.:Oi 1 ICE l3 ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1 919 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> x (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 Regulationa of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION1" 1 R C /L4 f fl CENSUS TRACT , <br /> Phone '93/- /rr'/'3 <br /> Owner's Name _LWc4 <br /> Address /b / City <br /> Contractor's Namer,�y�=.=�"-�' <br /> � / License 41,?If_7_6_/ Phone 444.993F <br /> TYPE OF WORK (Check) : NEW WELL !DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other 4L, � - .• : r,.s.Gyu <br />` DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> I SEWAGE DISPOSAL FIELD` CESSPOOL/SEEPAGE PIT OTHER \ <br /> INTENDED USE TYPE OF WELL <br /> 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 <br />! Other Rotary Type of Grout <br /> Other Other Information <br /> �+ 5 <br /> S <br /> PUMP INSTALLATION: Contractor <br /> H.P. fes` <br /> Type of Pump — <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work .Done <br /> ,DFsTRUCTZON OF WELL: We <br /> ll!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 /> r 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 t TITLE <br /> ( <br /> PL& PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE -I <br /> APPLICATION ACCEPTED .BY DATE r�`S <br /> ADD IT I ONAL.'-C,OMVENTS <br /> PRASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION R, <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> CALL FOR A-GROUT-INSPECTION-PRIOR TO-GROUTING AND FINAL INSPECTION. <br /> �T <br /> 7A14 5/731M <br />