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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> CE USE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 T7�. p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L--1-23 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San .Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /f�.�.S"f! - /!E!, , co CENSUS TRACT ' Sq 7 <br /> -� S ` <br /> Owner's Name � .�y R �.aN S� /y�d2�— Phone•--._.....---...-_-- <br /> 3- - �,�n.e �3, �✓ <br /> Address /s �'- _�i9.��YG' ..._ .,,._.,,......._._..__..—_.__..__,_...._ City , <br /> Contractor's Name 1f,10 H e- License # Phone <br /> TYPE OF WORK (Check) : NEW WELL R DEEPEN '/-/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION f7/ PUMP REPAIR / J PUMP REPLACEMENT /_7 ; <br /> Other / j — <br /> DISTANCE TO NEAREST: SEPTIC TA1K //O SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 9� ` CESSPOOL/SEEPAGE PIT OTHER MOM <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS u� <br /> Industrial ` �Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �_ Irrigation Gravel Pack Depth of Grout Seal -6 <br /> Other Rotary Type of Grout ��— <br /> . Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ .f�.A4m 40.c. IM- H.P. loft_1r- <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP ZEPAIR: / -/ State Work Done <br /> .DFRTRUCTION OF WELL: Well Diameter 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 4 <br /> and the State of California pertaining to or regulating well 'construetion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a4 <br /> WELL DRILLERS REPORT of the welX and notify them before putting the well in use. The above <br /> informatio is true to-t -best of my knowledge and belief. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COMMENTS: <br /> PRASE II G U C ION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE - /fj ,7,3 INSPECTION BY DATE -7-Z <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> E H 1426 5/731M l <br />