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_n.1QUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: lf,(11 E.. Helton Ave. , Stockton, Call.f. <br /> Telephone: (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PU;II' PERMIT Permit No. -1 3 1.1 k (' <br /> THIS PF.R11IT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-LI-2 <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 del.cribed. 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 /> JOB ADDRESS/LOCATION / <br /> ��y�cL CENSUS TRACT <br /> Owner's Name Ce� C _ Phone <br /> Address ��/ Z � /� �✓LGl�. City <br /> Contractor's Name .�L. 2?—_ License +l zdsTGi Phone 4,44 Q;S; <br /> TYPE OF WORK (Check): NEW IJEI,L /-7 -FEPEN /7 RECONDITION /-7 DESTRUCTION /-] <br /> PUMF INSTALLATION /-/ PUMP REPAIR /-7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: S'7PTIC TX4y SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER S <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privite _ Drilled Dia. of Well Casing or <br /> _ <br /> Domeatic;public Driven Gauge of Casing ' <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> _ Other _ Rotary Type of Grout <br /> other Other Information <br /> 1 <br /> PUW INSTALLATION: Contractor <br /> y Type of Pump H P. <br /> PUMP REPLACEMENT: /_/ State Work Done M <br /> PUMP REPAIR: /-7 State Work Done <br /> ,LFSTRUCTION OF WELL: Well Diameter Approximate -e nth <br /> Describe Material. and Procedure ; <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State o.' California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I w1II 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 Lest of my knowledge and belief. <br /> SIC:TIED G~ TITLE 4e:O � <br /> (U W PLOT N ON REVERSE SIDE) <br /> FOR DF,PARTMENT USE ONLY <br /> F}tASE I n/J V----Z <br /> APPLICATION ACCEPTED BY ,�GDATE �3 <br /> ALIDITIONAL COMMENTS: <br /> PHASE II GROUT INSPFriON PHASE/III/FI INSPECTION <br /> INSPECTION BY+ DAT>---- �►�en�, ►n*x T•- . .� �-� <br />