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ca <br /> \.e4N JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?9--3! 1W <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s// 7f, <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations pof� the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -7S / E �113 �T /QJ). Cyq41CENSUS TRACT <br /> Owner's Name /V/) Phone <br /> Address'' 2v E 1Rir Rry RD �E/�iL� r City CA/-T sI <br /> Contractor's Name le. , {*incense 11 / `.2 Phone - � 3.3g3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 / <br /> PUMP INSTALLATION /"// PLW REPAIR / / PUMP REPLACEMENT <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 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 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �)� n R.P. f' <br /> i'bW REPLACEMENT: /.State Work Done ///��szIO J��/" at <br /> l <br /> PUMP UPAIR: 17 State Work Done <br /> DFsTRUCTION OF WELL: Well Diameter Approximate Depth R <br /> Describe Material and Procedure 1�`\ <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 of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PijASE I <br /> APPLICATION ACCEPTED BY �. � . ✓� z.�/ DATE S S- <br /> ADDITIONAL CO'II,UENTS: _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION/ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL IOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> .. _ . _. <br />