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a J � <br /> SAN JOAQUIN LOCAL HEALTH -DISTRICT <br /> F .:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> TelephpAe:t (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued (21-AL) <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 work1herein described. ' This application is made in compliance with San Joag1 <br /> County Ordinance No. 186,#2 and th/e�Rules.. nd Regulations <br /> sscooff the San Joaquin Local Health Disgricl <br /> AS>� <br /> JOB ADDRESS/LOCATION SI a, � IU., `^�( <br /> Oy. , CENSUS TRACT O�7- /SL <br /> Owner's Name Df ,o r-1 S l��® N e✓ __ Phone �(' <br /> Address• J ,4"7J� c� o ��tYi City _y4_jt4: /_� <br /> c <br /> Contractor's Name t ] rJ�G� ei��l— License 11 /.gj�, phone 1-W i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /� RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /)C/ PUMP REPLACEMENT /-7 <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 <br /> ' Industrial Cable Tool Dia, of Well Excavation <br /> i <br /> _ Domestic/private Drilled " ' Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 4 Irrigation Gravel Pack Depth of Grout Seal <br /> - Other Yj' Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor 4v4,j �` <br /> "Type of Pump i H.P. <br /> y _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done J o `i f��'lll7� O�l� <br /> ,DF�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> with all laws and regulations of the San Joaquin11 Local Health Distri <br /> I hereby agree to co ly <br /> o or regulating well -construction. Within FIFTEEN DA <br /> and; the State of California pertaining t <br /> I will furnish the San Joaquin Local Health Distrii <br /> after completion of m� 'work on a new well, <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information is true t� .the best of my know age arid-belief. <br /> SIGNE➢ / E <br /> DRAW T PL ON RE . SE SIDE <br /> j DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTEAY <br /> ADDITIONAL COMMENTS: INSPE <br /> PHASE Il GROUT INSPECTION P <br /> INSPECTION BY i), DATE INSPBCTION B &N. <br /> DATE <br /> DVTnn Tn GRn11TTNC AND.FINAT IN CT __ <br />