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0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 0 1.601 E.: Hazelton-Ave. , Stockton, Calif. <br /> Telephone: , (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT Permit No. 7 7 <br /> THIS PERMIT. EXPIRES 1 YEAR-FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) jg!- 160 --09 <br /> Application is .hereby ma �e•to the San Joaquin Local Health District for a permit to construct ° <br /> and/or install the work herein described. Thisapplication is made in compliance with San Joaquin <br /> County Ordinance -No.-.,1862 and the Rules •and4Re9ulations of 'the San Joaquin Local Health District. <br /> �f7B l_5.34 icST7Nx <br /> JOE ADDRESS/LOCATION � ilG_S�_u _. ,NilGryrss� �,� on -CENSUS TRACT , <br /> Owner's Name2H r �t I QtlS<o✓ Phone '_bt � <br /> Address A- <br /> �D ' D`�7�. 40 10( City U �6C44���- <br /> Contractor's Name t,�}g��i � 0 License # Yj-rhone ' i='7G 4 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/- RECONDITION /_7 DESTRUCTION /—T <br /> PUMP,INSTALLATION / J PUMP REPAIR PUMP REPLACEMENT /7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> O <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS h <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 /> r <br /> PUMP INSTALLATION: Contractor7�d <br /> Type of Pump T" r b 0r,.- H.P. 0 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done GigH <br /> .DESTRUCTION Off' 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 u6e. The above <br /> information is true to the best of my knowle <br /> t ge elief. <br /> SIGNED <br /> ITLE <br /> � <br /> OT O(D W P PLAN N <br /> RAtt SE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: CoN <br /> 5 P SE II GROUT INSPECTION PIII FIN INSPECTION%�, �" <br /> INSPECTION BY _ DATE INSPECTION BY DATE � -1 -? A l/ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />