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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ?O _'OFFICE USE: - 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �- Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TAT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEISSUED Date Issued ,, -5-7 <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 11ea1th District. <br /> •.TOB ADDRESS/LOCATION .9-3 0/9 A/ 13 R L�.ELL Zj CENSUS TRACT <br /> Owner's Name G _ / y Phone <br /> Address 2- 3 a / 2 13 <br /> LULL E 2 City <br /> Contractor's Name License # 265-7,0 Phone e1646. <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/_/ RECONDITION DESTRUCTION /- <br /> PUMP INSTALLATION REPAIR /7/­PUMP REPLACEMENT /_7 <br /> other -/ f <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 <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 /> e . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �Gc /g%�1/ - _ -- H.P. ' 3'0 <br /> PUMP REPLACEMENT: / / State Work Done 4L <br /> t' PUMP TEPAIR: / Sta`ite Work Done �'"'•`�- '� <br /> i <br /> i ,DFATRUCTION OF WELL: Well Diameter Approximate Depth d <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 thein before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> s� <br /> SIGNED .iLy.�t� G' Vit•! / �u �2 tZ ���. c. TITLE <br /> ( RAW ' LOT PLAN ON REVERSE SIDE) <br /> . FOR DEPARTMENT. USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> l <br /> ADDITIONAL COZ01ENTS: <br /> .aa 14& 0144 Qgazk& <br /> PHASE II 120UT INSPECTION 0 PHASE III/FINAL INSPECTION/ <br /> INSPECTION BY,— DATE INSPECTION BY DATE <br /> CALL FOR-A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> c�� 5/731 <br />