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i"� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7OF. OFIICE .USI.: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br />` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued .�3 <br /> f (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 Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name RA _. __ Phone - <br /> Address / Ci.tylfG/�1�0�1 <br /> Contractor's Dame L Jt%' License # 74 a 2 Phone`/6Z-6-S9 7 <br /> TYPE OF WORK (Check) : NEW WELLY/ DEEPEN / / RECONDITION /—/ DESTRUCTION I—T <br /> PUMP INSTALLATION /—/ PUMP REPAIR J J PUMP REPLACEMENT <br /> Other / ! <br /> DISTANCE TO NEAREST: SEPTIC TANK ,7061°1- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r INS. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial. Cable Tool Dia. of Well Excavation <br /> I Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing . <br /> Irrigation Gravel Pack Depth of Grout Seal 13V _ <br /> Other �' Rotary Type of Grout C <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> #Type of Pump ,, H.P. . <br /> PUMP REPLACEMENT: J J State Work Done _lfa _i1-NiEa-___W4,W1/!/4F11/L <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DFgTRUCTION OF WELL::_ Well, Diameter O � App r im to Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the J acAin Loca Health is rict <br /> and the State of California pertaining to or regulating wet nuc ion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish t Joaquin Local Health District a <br /> WELL DRILLERS RE.PORT• of the well and notify them before putting the well in use. The above <br /> information is true to the best of my,knowledge and belief. <br /> SIGNED - . �� = TITLE <br /> (DRAW..PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � f�:. . <br /> APPLICATION ACCEPTED .BY' DATE �J aq `]3 <br /> ADDITIONAL COMYZNTS: �y,y <br /> PRASE II GROUTSPE TI �r P III/FINAL INSPECTION <br /> INSPECTION BYINSPECTION BY - DATE <br /> CALL FOR A G T ION_ PRIOR TO GROUTING AND FINAL INSPECTION.' _ <br /> F 9 7A79 11 <br />