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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 710I-:OFFICE USE: v .1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,? - 7_� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issucd f. -7�F <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 work herein described. , This application is made in compliance with San Jpaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION &gL eo (® CENSUS TRACT ' <br /> Owner's Name Phone 93 e-2:9- <br /> Ad.dress <br /> -2Address T 1&11 _A /.Qe - - -=- - City '°_ Ea <br /> Contractor's Name e� 4 : U 11 't G, License # L4&10Z Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION / 7 <br /> PUMP INSTALLATION / MP/ PUREPAIR '/—/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FI LD CESSPOOL/SEEPAGE PIT 'OTHER <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS Ilk <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ` <br /> Other Other Inf.armation l <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEAMNT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done N <br /> DFRTRUCTION OF WELL: Well Diameter " Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all lams 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 true o the best of my knowledge and belief. <br /> SIGNED—-d <br /> �. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE //9 <br /> ADDITIONAL COMMENTS <br /> P11AW I G T I38TECTION P II/FI INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DAT .�� <br /> CALL FOR A GROUT INSPEC ION PRIOR TO GROU TNG AND FINAL INSPECTION. <br /> ,. - C� /7-4 <br />