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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;?A /./ 41&j <br /> THIS PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED Date Issued _ ,2& <br /> (Complete In Triplicate) /-?cj_/1p _2,3 <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sm Joaquip Local Health District. <br /> JOB AD6RESS/LOCATION,000 o WAL Z162's D CENSUS TRACT <br /> Owner's Name G Phone <br /> Address Z�'O 7,q /y�ln//1�/fl Y 99 s' / city <br /> Contractor's Name /�� wG.GL oL QG�/P� C' d License <br /> TYPE OF WORK (Check) : NEW WELL XT DEEPEN /% RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER m <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / <br /> Iffigatilm V — Gra`del Pack - 'Dep'th of Grout- <br /> Other X_ Rotary Type of Grout L <br /> Other Other Information 4f011Vf 17,cr4 / C <br /> G�7f/f/PS <br /> PUMP INSTALLATION-. Contractor Y' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'.'tEPAIR: / / State Work Done <br /> ,DEgTRUCTION OF WELL: Well Diameter Approximate Depth IJ <br /> Describe Material and Procedure <br /> I hereby agree to comp—ly with all laws•and regulations of the San Joaquin Local Health District <br /> and the State of Califoinia 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 /> PHASE t L c�, . .. <br /> APPLIGA-TION-AZCEPT-ED-BY <br /> ADDITIONAL COMMENTS <br /> P INSPECTION PHASE III/F NAL INSPECTION <br /> INSPECTION BY DATE �L�_ 7�/ INSPECTION.BY,.�� DATE Ts <br /> CALL FOR IN PECTION PRIOR TO GROU—TING AND FINAL INSPECTION. `43 <br />