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k SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (,209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L- 93 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date 'Issued Z v <br /> (Complete In Triplicate) <br /> Application is here�y " de 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 Joaqui% <br /> County Ordinance No. 1862 and the ,Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J0rasp CENSUS TRACT <br /> Owner's Name + - .`P, :. Phone <br /> Address sY'J ?_a_. r� - �' City <br /> Contractor's Name License #1Jr?hone n74 7f, <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTLATION / / PUMP REPAIR / wP.UMP REPLACEMENT <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 v . <br /> Industrial Cable Tool Dia. of Well Excavation v <br /> C� Domestic/private Drilled Dia. of Well Casing J <br /> Domestic/pudic Driven Gauge of Casing - - <br /> Irrigation Gravel Pack Depth of Grout Seal m <br /> Other Rotary Type of-Grout- <br /> Other <br /> f-Grout-Other Other Information <br /> 4 <br /> PUMP INSTALLATION: Contractor ;, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /X State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .ESTRUCTION 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 mywork 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 nowle e a ief. <br /> i SIGNED LES,,( - <br /> (D W 0 ON REV SE SIDE - <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE rJ Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 8- DATE INSPECTION BY DATE -'10' <br /> CALL FOR A GROUT INSPECTION PRIOR._TO GROUTING AND FINAL INSPE64N. <br /> +, E H 1426 7/72 1M C:�- <br />