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!� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OPria USL; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., -.S-YK'9 j <br /> 73- G9i /° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued X23 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Disgrict. <br /> JOB ADDRESS/LOCATION �,��? Jj7, �' f/�/ (,/j f/� CENSUS TRACT <br /> Owner's Name / �/��� Q - Phone SGS--,3 -147 <br /> Address /6-0 City S7eclj l-oh/ <br /> Contractor's Name L4,AITX W6/U- 5t -r- 6 / fes 1- 6 , License # 744,92 Phone`f�Z-,9 89 7 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /—/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other/ J <br /> DISTANCE TO NEAREST; SEPTIC TANK <br /> z0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> j( Industrial Cable Tool Dia, of Well Excavation {Q <br /> I Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 9 l <br /> Irrigation Gravel Pack Depth of Grout Seal 7 ' <br /> Other X Rotary Type of Grout c`/,'j,-Alr <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> d Type of Pump -S",a H.P. � <br /> PUMP REPLACEMENT: J / State Work Done /PUN7'G N� bt9 Vf/CC� <br /> PUMP '2EPAIR: / / State Work Done <br /> ,DF1zTRUCTION OF WELL::_ Well Diameter <br /> leoY211-101 -dAppr im to Depth /z0 <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of thefi Jia in Loca Health` is rict <br /> and the State of California pertaining to or regulating wel n uc ion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish t A1,SLtl 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 tothe best,.of mys knowledge and belief. <br /> SIGNED 4 • � - Cl�`d' u Q TITLE 19L7- �i/✓G�• <br /> - (DRAW .PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ^` <br /> APPLICATION- ACCEPTED .BY' DATEk a� <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT SPE TI �' P III/FINAL INSPECTION <br /> INSPECTION BY TE-/I INSPECTION BY DATE <br /> CALL FOR A G IO _ PRIOR TO GROUTING AND FINAL INSPECTION. <br /> F A 7A9A e /' ,— i <br />