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v <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOF. OI, ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �uTelephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.lj-6_4z_ 7, , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE "ISSUED Date Issued/ <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 CENSUS TRACT <br /> Owner's Name A/cc Bqcyaov e- #o Phone <br /> Address T e_ City <br /> a <br /> Contractor's Name 44_t_ '- License ,/-d 2 WPhone .7-41 <br /> TYPE OF WORK (Check) : NEW WELL/7/- DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / ✓ MP PUREPAIR / / -PUMP REPLACEMENT 5R7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAiNK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <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 /> PUSH' INSTALLATION: Contractor r . <br /> Type of Pump H.P. .2, <br /> PUMP REPLACEMENT: ✓ State Work Done t �Y <br /> PUMP UPAIR: / / State Work Done <br /> DF-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 /> I 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--a d belief. <br /> SIGNE ¢� a ITLE <br /> RAW_P L-0 PLAN ON REVERSE SIDE) <br /> FOR ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE 16,4z--.3 <br /> ' ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION P INSPECTION <br /> INSPECTION BY DATE INSPECTION BY47E <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IION. <br /> x IA26 5/731M <br />