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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. may <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 `02_3_7Gl <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 Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a 31 W � r f} CENSUS TRACT <br /> Owner's Name1�VQ Pone <br /> -.� cam= <br /> Address 7 ) c7 1 city <br /> !�_ <br /> �1 14GK7'G!� -5r#4�V , <br /> J <br /> Contractor's Name Q E ogcj 1 A Dn 7 7 License #2SM72 Phone <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION , 4_'PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES � PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ,5� -�' 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 /> Dome st .c/public Driven Gauge of Zasinig <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br />'s Other Other Information - -PTEF . ' <br /> a _ . <br /> PUMP INSTALLATION: Contractor :F_K- <br /> Type of Pump —`i- A.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP UPAIR: - / / -State -Work Done - <br /> r <br /> I DFCTRUCTION OF WELL: Well Eiiametei - 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 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 /> informatio' is true to thbest of my knowledge and belief. <br /> i <br /> SIGNED 7-1-R`0' TITLE <br /> r; DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' FOR DEPARTMEUSE ONLY <br /> a PRASE I <br /> APPLICATION ACCEP QiQ DATE <br /> ADDITIONAL CO <br /> P S GROUT INSPECTION P E, II NAL- INSPECTION <br /> INSPECTIO I DATE / --2 O INSPECTIO DATE � Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5 . 731M <br />