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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO .'.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: {204} 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUN? PERMIT Permit No.,7!/_/7D <br /> THIS PERMIT.EXPIRES I YEAR FROM DATE ISSUED Date Issued 74- <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 Joaquint <br /> County Ordinance,No.•-1862 _and_the..Rules and Regulations of the San Joaquin Local Realth District. ,£. <br /> JOB ADDRESS/LOCATION -� / S O F+GUS NE G " �1 wiQ /� CENSUS TRACTSFs <br /> Owner's Name L Phone 1-9.3 - 7 / i <br /> Address _ q G!�E , S: S ,FX-Teel R-A - _ City A:S c q L aN C A L/P <br /> Contractor's Name — - � � License #2,6!;-7e.'1 Phone 4j'4,, <br /> TYPE OF WORK (Check) NEW WELL -/-7 DEEPEN /7 RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / Pi7MP REPAIR / / PUMP REPLACEMENT /_7 -� <br /> Other <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 k <br /> 4 Domestic/public Driven _; Cauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal f <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump !(g o H.P. .AQ 'el <br /> PUMP REPLACEMENT., State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> .PF1'-TRUCTION 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 'constructidn.-- Within FIFTEEN DAYS <br /> after completion of my work on a new well, I wrill. ._furnish the San Joaquin Local-Health District a <br /> 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 and belief. <br /> SIGNED ,dr/ TITLE <br /> (DRAW MY PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE .� <br /> ro � <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II G OUT INSPECTION PHASE 4.TIIZINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /.sem DATE 10-24y-,7�/ <br /> CALL FOR A GROUT NSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H .1426_ <br /> �_. _. 5/731M <br />