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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. {fl.> <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 411-9-70011 <br /> "­ r (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 Regulaticons of thg San Joaqu al Health District, <br /> JOB ADDRESS/LOCATi N � �13�1z UIC�r 1.� 6 1 Iviek CENSUS TRACT <br /> fLT l-itLl'rZ 0 <br /> Owner's Name [ Phone <br /> Address J iVEl"z C), Cit SG pN <br /> Y <br /> E <br /> Contractor's Name ����• License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEE _/ RECONDITION /_/ DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATIO . / PUMP REPAIR / / PUMP REPLACEMENT; 1/J? <br /> Other/. / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t <br /> s <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 /> x Domestic/public Driven Gauge of Casing ` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> fC t_. u P. C.. <br /> MP <br /> PUINSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:- / / State Work Done <br /> PUMP UPAIR: /_7 State work Done <br /> S/7 v '5-C.!]Vii] <br /> ,DFGTRUCTION OF WELL: Well Diameter Approxi ate 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 DRIL RS REPORT of the well and notify them before putting the well in use. The above <br /> informat'61is r e to th best of my knowledge and belief. <br /> SIGNED TITLE 54LEs A <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE 79 <br /> ADDITIONAL CO20ENTS: <br /> PHASE II GROUT INSPECTI PHASE /FINAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY 'DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />