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S^V JOAQUIN LOCAL 11EALTH DISTRICT <br /> FOR OFFICE USE: 160 4..,. Hazelton Ave. , Stockton, Cala..a <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. JZ, 7.5� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -]-7-1-7,?,- <br /> (Complete In Triplicate) <br /> 1pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> end/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 18662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION / ��3�n , S �/iq�/��Py /Cta� CENSUS TRACT <br /> Owner's Name /p/ Phone <br /> Address � • �O)C S� YPrulco �,/� Lq City <br /> :ontractor's Name 1 6DiJ{,— t2 License #165 761 Phone I/b/ - F-3 <br /> rCYPE OF WORK (Check) : NEW WELL / / DEEPEN / RECONDITION /7 DESTRUCTION / <br /> AL <br /> PUMP INSTLATION / / —PUMP REPAIR /—/—PUMP REPLACEMENT <br /> Other / / <br /> 31STANCE TO NEAREST: SEPTIC TANK/00 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PZT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information �1 <br /> PUMP INSTALLATION: Contractor Q <br /> Type of Pump SrJ iS 1" eve S 13 � �r H.P. <br /> PUMP REPLACEMENT: /Mate Work Done Xeplfee /{BOFP�S �SU!{�teitSi�S�q <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 /> 'SIGNED TITLE <br /> (D T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> —PHASE I <br /> APPLICATION ACCEPTED BY ' DATE 7"' � /r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTIONDATE INSPECTION BY ,DA 7 7 2 <br /> A <br /> CALL F A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 1 . <br /> E H 1426 �i/72 1M <br />