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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> COQ. 0 'F ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT. CONSTRUCTION OR PUMP PERMIT Permit No. ,7g- .L72&J <br /> THIS PERMIT EXPIRES I, YEAR FROM DATE. ISSUED Date Issued /.Z-3�7�f <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4 _ CENSUS TRACT -- <br /> r <br /> Owner's Name 97 Phone , <br /> AddressGU :. City'- ' <br /> Contractor°s Name Z:t AE M t-l"sO p 7V f_ License # Phone L-3 11 <br /> TYPE OF WORK (Check): NEW WELL J J DEEPEN '/ / RECONDITION /—/- DESTRUCTION /-7 <br /> PUMP INSTLATION � PUMP REPAIR / I PUMP REPLACEMENT J-T <br /> AL <br /> Other / / — — — W <br /> DISTANCE TO NEAREST: SEPTIC TANK JZ>&/ SEWER LINES Cdd/ PIT PRIVY � <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 Y A--Drilled Dia. of Well Casing iM <br /> Domestic/public Driven Gauge of Casing + 1 <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Other Rotary Type of. Grout ^- <br /> Other Other Information : N <br /> PUMP INSTALLATION: Contractor ;e <br /> Type of Pump ire 2H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> _ -41 - - - <br /> PUMP UPAIR: ,~ /f State Work Done �J4 <br /> ,DFgTRUCTION 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 <br /> 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 /> !E) <br /> SIGNED6- TITL <br /> (DRAW PLOT PLAN ON REVERSES <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICAT ON'ACCEPTED. BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE-11 GROUT IN ECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYr DATE /2..-x-:75/ <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M -- <br />