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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �r{{ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . rs , 73 <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 Focal. Health Disprict. <br /> Ac 4-77 E.AO—Ae4 <br /> JOB ADDRESS/LOCATION LUQ e , LugCENSUS TRACT 49(?-01(0-24 <br /> Owner's Name ,es rl Phone <br /> Address .'L �Z ZU GU G�141 �} • City <br /> Contractor's Name r�U �_ b V,,5 . License #;2 GP/,6Phone 23 Z <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /—/ RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 0-Ite�6tGrv�2 _SEWAGE DISPOSAL FIELD CESSPO�I./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 /> ;-C— Other Rotary Type of Grout <br /> a Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PULP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: / / State Work Done <br /> DFRTRUCTION 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 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 them before putting the well in use. The above <br /> iYIEoration is ru the best of my knowledge and belief. <br /> SD n x <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> -EPR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _1 _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY =.DATE 6E-- - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - - ' x/71 iM <br />