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SAN. <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> USE: 160Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> '---" APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z,! 3o.7q <br /> (Complete In Triplicate) permit to construct <br /> Application is hereby made to the San Joaquin Local Health District for a p <br /> and/or install the work herein described. - This application is wade in compliance with San Joaquin <br /> and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules <br /> JOB ADDRESS/LOCATION �, .� / 2 1 Y ' CENSUS TRACT <br /> Phone 93/�' /`85' <br /> Owner's Name lLac�► �Q d S - <br /> Address Z <br /> D city <br /> Contractor's Name ��irr.�da� �• �s —p-- <br /> License # 2& 7�.;L, Phone Lei� 5�S1'3� <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN /_7 RECONDITION / PUMPDESTRUCTION <br /> R RUCTIION/71_ <br /> PUMP INSTALLATION / 7 PUMP REPAIR <br /> Other <br /> DISTANCE TO NEAREST: PIT PRIVY <br /> SESEWER LINE <br /> WAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� <br /> l Cable Tool Dia. of Well Excavation <br /> Industrial <br /> Drilled Dia. of Well Casing <br /> DomeDomestic/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 H.P. �- <br /> Type of Pump <br /> PUMP REPLACEMENT: )E/- State Work Done <br /> PUMP 'tEPAIR: State Work Done <br /> .DF_TRUCTION OF WELL: Well Diameter <br /> 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 /> SIGNED <br /> y,^ TITLE <br /> } ,�,{ ��-E� ----a•� <br /> ( RAW PL PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PdASE I P <br /> 0 DATE 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p Z/FIN INSPECTION <br /> PHASE II G UT INSPECTION INSPECTION DATE <br /> INSPECTION BY DATE _ <br /> 7 CP <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731H <br /> F H 1426 <br />