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SAN JOAQUIN LOCAL HEALTH DISTRICT �## <br /> 1TOFAFFICE USE: 1601 E. Hazelton Ave: , Stockton, Calif. i <br /> - - Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a_z/.f7eL <br /> (Complete In Triplicate) i <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 /> i� <br /> JOB ADDRESS/LOCATION. k_, 1 WA I y /„Z 1-0421 CENSUS TRACT <br /> Owner's Name A N '7/t_ y N Y C 0/j Aa 7- A Phone 6!2-- -ro 3 7 ' <br /> Address / 2. 167 L41 Y / 'z City , i-61)I C_14 4- .. <br /> Contractor's Name 7WAL dA Ait-A License #a2.72 Phone 4/77 iftr-&-_ <br /> TYPE OF WORK (Check): NEW WELL/X DEEPEN '/77 RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTLATION f f PL* REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> Other /_7 ,. <br /> DISTANCE TO NEAREST: SEPTIC TANK 7LI SEWER LINES _ PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEPIT 1 OTHER 1i <br /> INTENDED USE TYPE OF WELL (CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. oflWell Excavation. /&` <br /> X Domestic/private Drilled —Dia. of-iWell Casing .. <br /> Domestic/public Driven Gauge of Casing ti <br /> _--- Irrigation — Gravel Pack Depth of Grout Seal s-6 ' <br /> Other X * Rotary.. Type of Grout C' T ` <br /> Other Other Information , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'TEPAIR: State Work Done <br /> ,DFsTRUCTION OF WELL: Well Diametei� /0 '' Approximate 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 DRILLERS REPORT 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 <br /> '(DRAQ P OT PL&XA0N REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ; <br /> PHASE I i <br /> t APPLICATION ACCEPTED .BY DATES / <br /> ADDITIONAL COMMENTS: Q' Ae <br /> PHASE II GROUT INSPECTION W P E IIT/FINAL INSPECTION <br /> INSPECTION BY 7,07 DATE INSPECTION BY DATE - " <br /> 0 <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> /711 y i <br />