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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 3s S 4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -iy-J3 <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 [ A f" CENSUS TRACT <br /> Owner's Name lyf A-S f) iPhone _ - 6? <br /> Address -- y. 4 /� �/f1//' �i City 7Lo k r W <br /> Contractor's Name C-44,1--)_LA_a 1*1---Z Z 4-f 0 1) �� ; License # `�G L G Phone -5:5-4 j <br /> TYPE OF WORK (Check): NEW WELk7ty�—IEEPEN W_ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /7 <br /> — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSJOTIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of - <br /> Casing �} �— <br /> Domestic/public Driven Gauge of Casing / d <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout /I A'i <br /> Other Other Informat on <br /> tet.vy1 <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION 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 the best of my knowledge and belief. <br /> '7 <br /> SIGNED . } TITLE <br /> f <br /> AW� FLOT PLAN ON REVERSE SID <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7—/r::2i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROWYWECTIGO P INSPECTIO <br /> INSPECTION BY TE INSPECTION DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS <br /> E H 1426 7/72 1M <br />