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e SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 ICE USE: 1601 E. Hazelton..Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2p(— ue-o-" <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 /> JOB ADDRESS/LOCATION FREME CLMR A7.r-,V OE ATTsTIX RT). CENSUS TRACT <br /> Owner's Nam �AA3 iREW_B.O.S, T , . . -- _-- WET;T• # Phone <br /> -- n <br /> AddressWAY <br /> -� City Mk.--CAI <br /> AI <br /> Contractor's Name pp <br /> MUNaq gam _ License #1 j 6' 22, Phond522 56}3 <br /> TYPE OF WORK (Check) : NEW WELL)V_/ DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR / / —PUMP REPLACEMENT /_7 <br /> Other <br /> N � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> a <br /> INTENDED USE TYPE Ok WELL CONSTRUCTION SPECIFICATIONS f _ <br /> Industrial Cable Tool Dia. of Well Excavation �r I <br /> Domestic/private Drilled Dia, of Well Casing 116M <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation X Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 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 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 th best f my kAowledge and belief. <br /> SIGNED TITLE <br /> {DRAW P ON REVERSE SIDE <br /> PHASE I LA DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ol <br /> PHASE II ROUT INSPECTION PHASE. I SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT/INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />