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� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR+OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. t <br /> JOB ADDRESS/LOCATION 50/D S Vvl4G N , CENSUS TRACT ' <br /> Owner's Name R Pte'. . �v� Phone <br /> � C _ 3 { <br /> Address �J f7/0 JQ GII� City �C . <br /> Contractor's Name NAh Af S C . License #14A3J Phone 5Z2 <br />- TYPE-OFWWORK-(Check)t 15EEPEN / RECONDITION/ DESTRUCTION /� _ <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT IST <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 5D -t- SEWER LINES -+- PIT PRIVY Nfda_: <br /> SEWAGE DISPOSAL FIELD , `-�- SSPOOL/SEEPAGE PIT Mnlf—= . OTHER NDN <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �" O <br /> Domestic/private Drilled Dia. of Well Casing h <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation �� Gravel Pack Depth of Grout Seal <br /> Other �C� Rotary Type of Grout I3F&IQN1 T� —. <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / - State Work Done <br /> PU1IP REPAIR: / / State Work Done <br /> . ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I� 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 6n 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 go 7te best of my knowledge. and belief. <br /> y SIGNED TITLE ekyl/�All <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> r FORD ARTMENT USE ONLY <br /> PHASE I <br /> �. APPLICATION ACCEPT-ED Y .DATE <br /> ADDITIONAL COMMENTS: tin <br /> PHASE II GROUT INSPECTION PHASE I I' <br /> /FINAL INSPECTION <br /> INSPECTION BY - DATE J Q 7Y �PNBX'f � ?_ / 'E�r`AATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> I E H 1426 4/72 1M <br /> F �_ J <br />