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N0� <br /> l� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> LPAYE 61Z Telephone: (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7;t1=// <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued -T--Ls' <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to -construct <br /> fand/or install the work herein described. This application is made in compliance with San Jo <br /> County Ordinance_No, 1862-and the Rules and Regulations of the Sa Joaquin Local Health Distr; <br /> �3vfp3re £ - G*dw'r-� Ao z f Oma: 2c^7-ee-a-CY <br /> JOB ADDRESS/LOCATION -E 1.,C4141tir , A $ /jay j r.r)v laISUS TRACT <br /> Owner's Name Lair;,,) s Phone 3g-7,06j: ' <br /> Address .a�A/JCV city <br /> � s Name <br /> Contractor' Noj <br /> F" 2� gz.-) License # 9J1b Phone <br /> i TYPE OF WORK (Check) : NEW WELL '/-7 DEEPEN '/_ RECONDITION / D DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR,/% PUMP REPLACEMENT <br /> j Other•:/ / <br /> f! 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 <br /> Domestic/ptivate� Drilled Dia. of Well Casing <br /> DomesticJpulic� Driven Gauge of Casing <br /> Irrigation Gravel'a k Depth of Grout'$eal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor t1 <br /> `I Type of Pump _ H.P. . <br /> ( PUMP REPLACEMENT: <br /> {! AV State Work Done ��,,,,� ,�/.�p &ab a .724Aale c?A0 S ,X <br /> PUMP 'zEPAIR: /� State Work Done <br /> i <br /> :PF-MUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I. hereby agree to comply-with all laws and regulationa:of the San Joaquin Local Health Distric <br /> and the State of California pertaining to or regulating well'construction. Within FIFTEEN DAY <br /> after completion ofmy work on a new well, I will furnish the San Joaquin Local Health Distric <br /> i WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information is true:to the beat of my knowledge and belief. <br /> 1 SIGNED TITLE <br /> U (DRAW PLOT PLAN ON REVERSE SIDE <br /> t FOR DEPARTMENT USE ONLY — <br /> i PHASE I <br /> APPIICATION ACCEPTEDBY DATE _3 LICL_�jG <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FIN INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY Atjl DATE <br /> CALL unu• A r_nnt,m <br />