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I JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE6 SE: 160 . Hazelton Ave. , Stockton, CalS-r. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,5 f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / G <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 andtheRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J ��+5 Z ��j {Jy�k r CENSUS TRACT <br /> Owner's Name li(9 t q Yyt O i l h q oh ? ,n»Q Phone <br /> Address ) L, Liu n G City LGG t/, 4 p` <br /> Contractor's Name L�7`2gbt1 Q// -„Le , 7 License # & ZZJ'-Phone q4 .L- 7,(,7 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /-7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /) PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> CIO <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Soo <br /> _ C Domestic/private Drilled Dia. of Well Casing oe <br /> Domestic/public Driven Gauge of Casing (n <br /> Irrigation Gravel Pack Depth of Grout Seal , <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> F. <br /> PUMP INSTALLATION: Contractor 5yyo4c.// mak .Q Z <br /> Type of Pump V Tu4- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> ,DESTRUCTION 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 true to the best f-,my knowledge, and belief. <br /> SIGN Y• GlJ - TITLE <br /> XDRAWLOT PLAN 0 VERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f z 3r -/ ,5 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR S C N PHASE III FINAL INSPECTION <br /> INSPECTION BY V DATE INSPECTION BY G DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI09. <br /> E H 1426 7/72 1M WA� <br />