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SAN- JOAQUIN LOCAL HEALTH DISTRICT v h <br /> FOF.7OFFICL' USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued lam/"7r <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 wo* herein described. - This application is made in compliance with San Joaquin <br /> County Ordinance No. 11862 and the Rules and Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name II ^-KAAt,6, V (� Phone L4 - 777 /oOW <br /> Address Pd+ 1,5_47 zi : City <br /> m <br /> Contractor's-Name �dw�A�[ r�dd6deg License U Phone'/(4- <br /> TYPE OF WORK (Check) : NEW WELL K-'DEEPEN '/7 RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION X1 PLMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK r 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 /> h <br /> Domestic/privat Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing y('F41/G'e P U G <br /> Irrigation Gravel Pack Depth of Grout Sjal, <br /> T Other _ Rotary Type of Grout <br /> Other Other Information <br /> R <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. J <br /> is <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <br /> i <br /> 4 PUMP 'tEPAIR: /7 State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby agree to co ly 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 FIF'T'EEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Districta <br /> WELL DRILLERS REPORT bf .the well and notify them before putting the well in use. The above <br /> information is true t°o the best of my knowledge and belief. Q <br /> 4q r7 <br /> TITLE ' <br /> SIGNED 1G .& <br /> s <br /> fl (DRAW PLOT PLAN ON REVERSE SIDE <br /> { FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED Y t' ' 7 DAT <br /> ADDITIONAL COMMENTS: p <br /> /FINAL INSPECTION <br /> PHASE III <br /> PHASE IS GROUT INSPECTION ATE Lam- <br /> INSPECTION BY 0 DATE INSPECTION BY Dc/ <br /> CALL FOR A GROUT INSPECTION PRIOR-TO GROUTING AND ,FINAL INSPECTION. 51731M E.p <br /> E H 1426 -- tl <br />