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��/�SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL., ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L,2,f GJ <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE "ISSUED Date Issued /,Z-/7 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 iixstal.l the work herein described. ' This application is made in compliance with Sari Joaquin " <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Realt1i District. <br /> JOB ADDRESS/LOCATION � � r CENSUS TRACT <br /> y <br /> Owner's Na-ime / . Phone <br /> �3 - <br /> Address ^ • 3 / 'l 77 ��' City `� '7'1 <br /> Contractor's Name Lam_" �J !✓ f�D�[]� _ License' # Phoneme <br /> • 5 <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTAL" TION / / PUMP 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 /> Dommestic/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 --2-'-ar APF <br /> Other Other Information " <br /> r <br /> i <br /> PUMP INSTALLATION: Contractor .�' �"Ir✓�d� '! <br /> Type of Pump f H.P. " ; <br />...-PU11P-"REPLACEMENT-:- . '/-/ State Work Dane = ' ' <br /> PUMP TtEPAIR: State Work Done 4 <br /> ,DF-ZTRUCTION OF WELL: Well Diameter Approximate depth <br /> Describe Material and Procedure <br /> I her 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, T 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 /> information s true to ,ttse best of"my kno edge and belief. <br /> SIGNED TITLE <br />{ <br /> W PLOT PLAN ON REVERSE SIDE <br /> V FOR DEPARTMENT. USE ONLY <br /> PILA I' _ <br /> AP LICATION ACCEPTED .BY DATE --I <br /> ADDITIONAL COMMENTS: <br /> Pf , PECTION PHA,8yA1W1/FIN SPECTI N <br /> INSPECTION BY DATE /?. INSPECTION BY TION. E <br /> ., CALL FOR T" C ON PRIOR. TO GROUTING AND FINAL INSPEC <br /> .5/731M <br />