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SAN JOAQUIN LOCAL HEALTAISTRICT <br /> Of. <br /> � ,O1-FICE USE: 1601 E. HazelH C <br /> Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_60-6 <br /> W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-f-Z-2 - <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 Mork herein described. ' This application is made in compliance with Sant J,paquin.' <br /> County Ordinance No..// 1862 and the Rules and Regulations of the San Joaquin Local: Health District. <br /> .TOB ADDRESS/LOCAT&I�JE. - CENSUS TRACT � <br /> Owner's Name Phone/ [ / ���-- dc 30_ <br /> Address , City ' <br /> Contractor's Name 11611215 YOB. I"/. License # 91j�i3 Phone 57-�57a <br /> TYPE OF WORK (Check) : NEW 'WELL lj;K DEEPEN '/—/ RECONDITION / I DESTRUCTION /_7 <br /> PUMP INSTALLATION 'UMP REPAIR / J PUMP REPLACEMENT /_7. Other J / _ — ---- <br /> DISTANCE TO NEAREST: SEPTIC TANK iB p SEWER LINES PIT PRIVY <br /> Nt SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> t/ Domestic/private Drilled Dia. of Well. Casing do <br /> Domestic/public Driven Gauge of Casing <br /> I'P Irrigation Gravel Pack Depth of Grout Seal <br />'Gw Other _ ✓ Rotary Type of Grout <br /> Other Other Information cf kill `j am a-ju12&i` - <br /> PUMP INSTALLATION: Contractor <br /> Type of- Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> C - <br />'+ PUMP 'ZEPAIR: / / State Work Done <br /> DFsTRUCTION OF WELL: Well Diameter Approximate Depth \ <br /> Describe Material and Procedure <br /> i <br /> r= <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 we11 '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 /> r <br />' information is true to the best of my knowledge and belief. <br /> SIGNED .V•.YC.rxnr� G�...�.�.C. TITLE <br /> i Tom . (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR TMENT USE 0 LY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITI <br /> ONALCO <br /> INSPECTION PHASE I FINAL INSPECTION <br /> INSPE DATE �Z 7 INSPECTION BY ,-4-��-- DATE--,;Z1 CALL FOR FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E <br /> .5`731M <br /> H 1426 ^` - _ <br />