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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 71VUT.-OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zf �,ZajO <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .,7-jZ-;,y <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 q:3 <br /> 6e Al CENSUS TRACT <br /> Owner's Name Ves a Phone <br /> Address !,:A, Jr, City <br /> V .0 <br /> Contractor's Name C'-, -V License # 2� Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/—PLW REPAIR Y/—PUMP 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump M x fi H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP nPAIR: State Work Dane j- grwW �4,;2AI <br /> V � V <br /> ,DFqTRUCTION 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 knowl e a -dr, lief. <br /> A;:�.IL A 4,11- <br /> SIGNED <br /> ILOT a SW <br /> E SIDE) <br /> U \,-VDR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHAS INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY /-V/1 ////1 -"" <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPJ�� <br /> E H 1426 Uo- 5/731M <br />