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r me SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I E: 1601 E. Ratelton'Ave., Stockton, Calif. <br /> TelephoneiT� (209),466-6781 <br /> APPLICATION FOR WELT. CONSTRUCTION OR PUMP PERMIT Permit No. y4_ /d�✓ <br /> 74, s7 <br /> ' <br /> THIS PQwlQT EXPIRES 1 YEAR FROM DATE ISSUHD Dace Iaeued <br /> (Complete In Triplicate) ' <br /> Application Is hereby rde to the San Joaquin Local Health District for a permit to construct <br /> And/or install the work barrio described. This application is masa in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sar Joaquin Local Health District. <br /> f / <br /> JOB ADDNEBS/LOCATION /7�Y4� .Af VAF atp°L -Z,--OLII CENSUS TRACT <br /> //��H „ <br /> a e <br /> Owner's Mar Q/ <br /> �� ,•t+-46, Phaoa <br /> Address .. - City 46r(o <br /> Contractor's Name G .SE' 6_ License P Phone N <br /> a <br /> TYPE OF,WORK (Check): NEG WELL 0 DEEPm /-T_ RECONDITION / DBSTRUCTIONv——- <br /> PUNY INSTALLATION 0 PClP REPAIR /7 PUMP RBYLACHMENT /7 <br /> other 1-7 <br /> DISTANCE TO NEAAF.ST: SEPTIC TANK O SEWER LINES _& PIT PRIVY <br /> SEWAGE DISPOSAL FIELD_ CESSPOOL/SEEPAGE PTT _ OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial CAbleTool Dia. of Well Excavation <br /> _ Domaetic/private Drilled Dia. of Well Casing <br /> _Domestic/public —Driven Gauge of Casing /Z <br /> _ Irrigation Gravel Pack Depth of Grout Seel / <br /> _Other —!,,RRootary Typo of Grout 4A r <br /> _�dptber a. Other Iaforastion <br /> Pule-INSTALLATION. CDetrsetor' " 'G riM SQ <br /> '*Pe Of H.P. 'r , <br /> PUMP REPLACKKSKT �-1 j State Work Dom <br /> PUlP 'REPAIR:V� _��• Srace Work Done ell - <br /> "W�' Approximate <br /> ,MSTRO(:TTON OF WELL:- Diameter _ APP Depth <br /> i Ueecribe Xateii-iT and Procedure <br /> I hereby agree f eo forol p all lave ofd r crugoliooa of well <br /> San Joaquin Local Health District <br /> YS <br /> and the States of California an A new wall,to vI willfamiAtia& we 11 Sam Joaquin. Within lth Di M DAIS <br /> aEtar eota.zBS RE of my work we a and f I will before <br /> p the Eon Joaquin Local Health btore ct e <br /> DELL DAILLF35 REPORT of the well and notify them before putting the well in use. The above <br /> Information,is true to the beet of ay knowledge and belief. <br /> SIGNED TITLE - M`h� <br /> G <br /> TfT (DRAM PIdT PINI ON RHVERSB SIDe) <br /> � �R DEPAATlfl!11T USE ONi.Y <br /> PNARE I . <br /> ' APPLICATION ACCEPTED BY <br /> DATE _2/9-7T <br /> ADDITIONAL COMMENTS: <br /> Paxsv. II GROUT INSPECTIOIt - PHOS III YINAI. INRP ION <br /> INSPECTION BY E DATE INSPECTION R DATE - <br /> Call POR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEiCTION. $�731M <br /> E H 1426 1 <br />