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j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POO. OFFICE US ,': 1.601 E. Hazelton Ave.' , Stockton, Calif. <br /> fi Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T_5-�a 0 <br /> THIS PERMIT 'EXPIRES l YEAR FROM DATE ISSUED Dote Issued Z7_3 <br /> (Complete In Triplicate) - 2,70 -1G <br /> Application is hereby made t: 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 Jba ui <br /> n+ <br /> ; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Dis riot. <br /> � q � <br /> JOB ADDRESS/LOCATION Nor "`- Y►�i;7 "� off - V CENSUS TRACT ' <br /> F <br /> Owner's Name G Al- l C hone <br /> Address S S-0 IU I-K 0 o A.d W a-14 City <br /> Contractor's Name to 9A.tit. License # �'hane <br /> t a-A,_74741* <br /> TYPE-OF WORK (Check) : NEW WELL/ / DEEPEN/_/ RECONDITION / / DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION J / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC; TAINK 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 /> Domestic/private l Drilled Dia. of Well Casing <br /> Domestic/public A Driven Gauge -of Casing <br /> Irrigation i Gravel Pack, . Depth of Grout Seal <br /> Other ! Rotary .p Type of Grout <br /> I Other Other Information t <br /> PUMP INSTALLATION; Contractor Pte, nt- <br /> Type`"of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I �r <br /> PUMP -%z2A!*R: ,State Work Dane .�•.��` _ <br /> DFgTRUCTION OF WELL: ' Well,Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f 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 workk'on a new well, I will furnish the San Joaquin Local Health District a <br /> t <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. ' The above <br /> information is true to the best o rc►y k w €cige d belief. <br /> SIGNE _ O40Qt� Ga.� <br /> (DJB W PLT PLAN ON REnRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> i APPLICATION ACCEPTED BY D <br /> ADDITIONAL COMN,ENTS: 40 <br /> PRASE II GROUT =INSPECTION PHAS INSPECTION <br /> INSPECTION BY ,DATE INSPEC ION BY DATE y. <br />{ <br /> CALL FOR A GROUT INSPECTION PRIOR TO .GROUTING AND FINAL IN E 'T <br /> E H 1426 5/731M tF <br />