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S)ar JOAQUIN LOCAL HEALTH DISTRICT U <br /> JE. OFFicu US L': VVV 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 5%t{07/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '—�/7� <br /> (Complete In Triplicate) <br /> ??lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> n4/or install the work herein described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> IT- <br /> Oa ADDRESS/LOCATION /"S,, cf "i c/ 152 to 40e CENSUS TRACT <br /> wner's Name aa-&l lc:7-4 k- / y> E l l C _ Phone <br /> Adress ,\\f� City <br /> :ontractor's Name �J P ! 7 Gti ��lt 1�1 O� License # &A3 <br /> 'Y2E OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / <br /> AL _/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PLW REPAIR / / PUMP REPLACEMENT 1-n <br /> Other <br /> )ISTANCE TO NEAREST: SEPTIC TANK -SEWER PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> k Industrial Cable Tool Dia. of Well Excavation <br /> _?c 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 O <br /> Other Other Information <br /> 'u L INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> pvncU� 3 � �[<aG/r�C tnSf4A(/ <br /> PUNP REPLACEMENT: State Work Done S , / y,F ri Ale <br /> 'UMP ZEPAIR: / / State Work Done <br /> ,FgTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> .,nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter complet' y work on a n well, I will furnish the San Joaquin Local Health District a <br /> ;::LL DRILL�REPORT of the well nd not�f them before putting the well in use. The above <br /> Lnformati6n is true o the best m !_).edge /and belief. /J /� <br /> SIGNED ., �.1 TITLE,. hva ,..Z-LLf� QyF' <br /> (D W PLOT PLAN ON REVERSE SIDE) <br /> ZCI <br /> 2;iASE IDATE )/ 7 5:PILICATION ACCEPTEDBY <br /> aDITIONAL C 0E-NTS: 11 7 PHASE II T INS P SEI /FIT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. 5/731M <br />