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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160.1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 3 -/10/0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �3 <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 _ - a_IR-R CENSUS TRACT <br /> Owner's Name j / Phone <br /> N Address . <br /> Q`,� C A. City � ,Cd s1 <br /> S <br /> Contractor's Name �, �� ,[�,y„� n,J License # f C) Phone - <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /P-'-PUMP REPAIR / / PUMP REPLACEMENT /X7- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 00 <br /> r* <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 'r <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of,Well Casing <br /> Domestic/public Driven Gauge of Casilig <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pump - � c •- tom- H.P. / <br /> PUMP REPLACEMENT: /�' State Work Done Z22&6 S 1 4-TA J . <br /> k. PUMP-REPAIR: . v /—/ State Work-Done` _ <br /> RESTRUCTIbN OF*3WELL:� 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 per 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 /> f WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is t ue to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> A7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPTED BY DATE ' S <br /> ADDITIONAL COMMENTS: <br /> PHASE II 9,AOUT INSPECTION PHA WK#AL INSPECTION <br /> INSPECTION BY DATE INSPECXIOQNE B DATE <br /> CALL FOR A GROUT iNSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/7-2 1M <br />