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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. _ <br /> Telephone: (209) 466-6i$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 130. 73 3 <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ,Application is hereby rade to the San Joaquin Local Health Distract for a permit to construct <br /> and/or install the work herein described. - This application is made in compliance with San Joaquin <br /> County Ordinance -No. 1862 and the Rules and Regulations of the Sawn Joaquin Local Tiealth District. <br /> .TOB ADDRESS/LOCATION STHKC_�YBLVD iCROSS HWY 580 CENSUS TRACT —253-- 0Q0-Z3. <br /> Owner's Name Ralph pombU 3k'4,$K2N*9dQbW <br /> xx Phone 835-1+247 <br /> Address 5760 West Delta 2=XXX City ' Tra-ey, Cal. <br /> Contractor's Name License # 116322- Phone 572_564. <br /> TYPE OF WORK (Check) : NEW WELL /x// DEEPEN '/ 1 RECONDITION I 1 DESTRUCTION 1 T V� <br /> PUMP INSTLATION REPAIR-/ / PUMP REPLACEMEk T L <br /> AL �? <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK 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 1014 <br /> j . Domestic/private Drilled . Dia. of. Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irri tion X Rotary Type of Grow <br /> n R Gravel. Pack Depth of Grout Seal t <br /> Other <br /> g o t <br /> �` Other Other Information ' Slab y comer <br /> PUMP INSTALLATION: Contractor ti <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'kEPAIk: State Work Done _ <br /> DFSTRUCTION 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 <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 truetoto the best of -my knowledge and belief. <br /> € SIGNED/� r � TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i PRASE I DATE f} 1-3 <br /> APPLICATION ACCEPTED .BY --- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7�73- <br /> - CALL FORA GROUT-INSPECTION PRIOR TO GROUTING AND FINAL INS CTION. <br /> - 11 , 1-1 5/.731M <br />