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� - t <br /> e <br /> SAN ',JOA' <br /> QUIN LOCAL HEALTH DISTRICT <br /> FOF.�OFFICE USE: 1601 E. Hazelton 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 <br /> (Complete In Triplicate) <br /> Application is hereby :Wade 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 Re ulations f the San Joaquin Local Health District. <br /> gq_b N Nl <br /> .TOB ADDRESS/LOCATION ENSUS TRACT <br /> Owner's Name kl Ll -' a Phone 3 ,. . o <br /> t, Address �' o !Z City /_fJ cL ! <br /> I <br /> Contractor's Name �� 27i t9c. 2.-- 01f License #16 -).371 Phone34&tA <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/_/ RECONDITION /—/ DESTRUCTION /_7 1 <br /> PUMP INSTALLATION / / PUMP REPAIR J3--PUMP REPLACEMENT /_7 n'. I <br /> Other ./ / V" <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 (�"o'' <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 LT A- - <br /> Type of Pump C� it Q H.P. F, <br /> PUMP REPLACEMENT: State State WarkYbane <br /> PUMP UPAIR• State Work Done ZRt <br /> ( K 1VS z - L <br />` DFCTRUCTION 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 any work on a new well, I will furnish the San Joaquin Local Health District al <br /> WELL DRILLERS REPORT of .the well and notify them be€ore putting the well in, use. The above <br /> information is true to the best- of my knowledge and belief. s° <br /> SIGNED TITLE <br /> jt!tQRAW PLOT PLAN ON REVERSE SIDE) , <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL CO�MNTS: 7 7 <br /> PHASE II GROUT INSPECTION PHAM III/FINAL INSPECTIO <br /> INSPECTION BY ��� DATE INSPECTION BY - DATE <br /> CALL FOR-A GROUT INSPECTION-PRIOR-TO-GROUTING AND-FINAL INSPECTION. <br /> E H 1426 C�/7-4 <br />