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(L L <br /> F6 OFFICE USE• V SAN _'C"" IN LOCAL HEALTH VISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATJON POR WELL CONSTRUCTION OR PUMP PERMIT Permit No. •'� <br /> THIS PERMIT E7pIRE I1 YEAR FROM DATE ISSUED Date Issued 1J <br /> Application is hereby (Complete In Triplicate) <br /> and/or install made to th.: San .Joaquin Local Health District for a permit to construct <br /> / a tall the work herein described. This application is made in compliance with San Joaquin; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOE ADI/LOCATION U j Z, <br /> VL 1/' <br /> Owner's Name _ � CENSUS TRACT <br /> .t� L <br /> Address 11 5 � ,�' � % �y Phone <br /> Contractor's Name � City <br /> ��u"� eJlw� � Phone G� G,?S <br /> e:a ' 1 License f --L'-5� <br /> TYPE OF PORK (Check): NEW WELL. / / DEEPEN /_7 RECONDITION 1-7DES�ON / <br /> PUMP INSTALLATION <br /> Other PUMP REPAIR �/ PUMP REPLACEMENT /I <br /> / / _-._-_-- <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> SF'N'ER LINT: IT PRLVT <br /> SEWAGE Di SPOSAL FIE[D <br /> CESSPOOL/SEEPAGE PIT OTHER _ <br /> INTENDED US' yypE OF' WFI:- <br /> _ Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic Cable 7001 Dia. of Well Excavation - <br /> /private Drilled " r <br /> Domestic/public D/a. of Well Casing 1. <br /> Irrigation Driven Gauge of Casing l1114 LJ Ij <br /> Other Gravel Pack Depth of Grout Seal <br /> _ n p <br /> �- Rotary I� <br /> Other Other <br /> of Grout <br /> --- Other Information fn <br /> N I T. <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump _ <br /> H.P. <br /> / <br /> PUMP REPI.AC3MENT: / State Work Done _ _ -•� <br /> _ n <br /> PUMP REPAIR: /:•`: V A•',%;e,.•,el:.. <br /> IX/ State Work Done <br /> � - �•- - Oil <br /> ,DESTRUCTION JF WELL: Well Diameter <br /> Describe Materia] and Procedure Approximate Depth <br /> I hereby agree to comply with all taws and reJ;ulations of the San Joaquin Local Neal[h District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after DRILLERS <br /> RE 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 h , <br /> n . ._. <br /> TITLE &'I . <br /> _ (DEW PLOT Pi:AN <br /> ON REVERSE SIDc)�- r-�.y <br /> PHASE IA�RT—ME-N7 USE ONLY -gym <br /> APPLICATION ACCEPTED B�� / ✓ C/ �o <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE <br /> J� <br /> SE II GROUT i•:SPt CT?ON — - <br /> INSPECTION BY— - ^HA II/F NAL 2NSPFCTION <br /> DATE INSPECTION By <br /> ^0'�n DATE / -�/'7 <br /> CALL IOR A GROIM ♦vent.-....... ........ _ tom._ <br />