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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 /> r, THIS <br /> ATION FOR WELL CONSTRUCTION OR PUMP PERMIT . Permit No: lu_XY <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .l: rfG P --, ,0 r� CENSUS TRACT <br /> Owner's Name _ A I& ej _ _ _ Phone <br /> Address tit City � <br /> Contractor's Name iM ' License Q& 7 Phone f*),•'7476 <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN / 7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ 71PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 11 of <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Too! Dia, of 'Weil -Excavation T <br /> Domestic/private Drilled Dia. of Well Casing {D4. <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other a. Rotary Type of Grout <br /> Other Other Information <br /> �M I <br /> PUMP INSTALLATION: Contractor " <br /> Type of Pump f H.P. t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /x/ State Work Done [��/^A?ed re4 .r,..dorZ N." 4,4s,eLX Oo <br /> �,,, lJ�,• � <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure . <br /> z <br /> I hereby agree to comply with all lams 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 /> �-- <br /> SIGNED . �� � (TLE � - <br /> I� (D W ON RVYRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C7- - DATE ID Y <br /> ADDITIONAL COMMENTS: <br /> PHASE II ` ROUT INSPECTION PHASE III F AL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY !� 7 <br /> CALL FOR A GROUT IN�SPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 . N /72 IM <br />