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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT Permit No. 'j�,y Sl <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE'ISSUED Date Issued <br /> 2_17Y <br /> (Complete In Triplicate) <br /> Application.,is,.hereby male 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. Rule's nd Regulations of the San Joaquin Local Health District. <br /> JOB"ADDRESS/LOCATION , �'.• � ; wo �B2r�/ CENSUS TRACT oZ3-22-37 <br /> Owner's Name n „ ' Phone <br /> Address .ter — (gip-(7. City <br /> Contractor's Name / AP , License p )�2,1760 Phone <br /> LZ <br /> TYPE OF WORK (Check) : NEW WELL/ 7En EPE��N /-7 RECONDITION /- . DESTRUCTION/-7 <br /> AL - ' <br /> Pl7MP INSTLATION .�' PUMP REPAIR /-. PUMP REPLACEMENT /� <br /> OQher / J <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWtAGE DISPOSAL FIELD SPOOL/SEEPAGE PIT OTHER <br /> it m NN-!_ t U/�� OOI�f Uri D i Rn �P/y1LL�d-OoO�� i' 1 1 +s, <br /> C <br /> IATENDED USE- - TYPE OF WELL _""-CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled' Dia, of Well Casing <br /> Domestic/public Driven` Gauge of Casing <br /> -b. Irrigation GravelSPatk Depth of Grout Seal j • <br /> Other Rotary' , Type of Grout J + <br /> Other 1 Other Information <br /> PUMP INSTALLATION: <br /> CoYntractor <br /> Type of Pump N.Y. <br /> PUMP REPLACEMBNT: / +/ State Work Done , <br /> 1 ' �� 1 1 <br /> ,PUMP REPAIR: S rA to Work Done <br /> -+ --•��� _-�j •- <br /> :;DESTRUCTION OF WELL: Well Dia to 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 i true to th"e_ 6t of my knlfowledge and belief. <br /> SIGNED Vim/ (`'� '� I .! / TITLE, <br /> 4DRAW_PLOT PLAN ON REVERSE SID <br /> PHASE l <br /> FOR DEPARTMENT USE ONLY <br /> " a ` , <br /> APPLICATION ACCEPTED BY 666 <br /> A" TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FIM:-INSPECTION <br /> INSPECTION BY DATE INSPECTI6N-BY' s/ - DATE /`•7 Z� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL rINSPECTION ' <br /> E H 1426 1�` `4/72 + 1M <br />