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Q/a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS. QFICg USL': 160i E. Hazelton Ave. , Stockton, Calif.. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> !� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued c/ --3-7� <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 Sart Joaquin <br /> County Ordinance No. 1862 and` -the Rules and Regulations of the San Joaquin..Local 14e.11th District. <br /> JOB ADDRESS/LOCATION U r` 4- 0 '� _ CENSUS TRACT <br /> Owner's Name C/-A !i-YZ Ley '( L _ Phone ' <br /> Address City ' <br /> Contractor's Name 11 [ CZl..1'`x'1 C 5 454 � !�iLicense # PhoneSYq-- <br /> TYPE OF WORK (Check): NEW WELL IL7- DEEPEN '/ J RECONDITION/ / DESTRUCTION /-7 <br /> PUMP INSTALLATION / I PUMP REPAIR I �/, . PUMP REPLACEMENT /_7 <br /> Other �` . <br /> ,p <br /> DISTANCE TO NEAREST: SEPTIC TANK 7-0- SEWER LINES d>0 PIT PRIVY p ' <br /> SEWAGE DISPOSAL FIELD . CESSPOOL/SEEPAGE PIT OTHER rrN, <br /> TYPE OF WELL -£OIVSTRUCTION SPECIFICATIONS <br /> INTENDED USE '::,- �. ��' - <br /> Industrial 3 _ :G Cable Tool Dia, of ,Well Excavation t <br /> it '\ <br /> �!/Domestic/private s� i,ll_ vrilled =Dia:: of'a We11 Casing r <br /> Domestic/public Driven Gauge of Casing �J) <br /> Irrigation Gravel Pack -Depthof-Gtout Seal <br /> Other Rotary Type of Grout Q <br /> Other Other Information <br /> ii <br /> li S 5 rzr•Cf . <br /> PUMP INSTALLATION: Contractor e��-/LLC-i.N�'T -AJ <br /> Type of; Pump H.P. ' <br /> F PUMP REPLACEMENT: / / State;Work Done <br /> PUMP 'REPAIR: Work -Done <br /> pFgTRUCTION OF WELL: ' Well Diameter Approximate Depth el <br /> Descrii,e Material. and Procedure <br /> I hereby agree to comply withIall 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 oz� a new well, I wi.11'_furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of .the we11 and notify them liefore putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> ° TITLE <br /> SIGNED '`- <br /> (DRAW PLOT .PLANT ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ti <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL CO:DMNTS: <br /> PHASE II GROUT INSPECTION PRASE NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY" <br /> ' - CALL FOR A GROUT IN PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />