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ir <br /> SAID OAQUIN LOCAL HEALTH DISTRICT <br /> F' � i <br /> FOR OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif., <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR 14ELL CONSTRUCTION OR PUMP PERMIT Permit No.�.Z /pip w <br /> THLS PERA1.1' EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /� L <br /> (Complete In Triplicate) <br /> Application is hereby made r--.. the Sara 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. 18!62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOA ADDRESS/LOCATION 1 201 CENSUS TRACT <br /> Owner's Now � /��� Phone <br /> Address lO� J �k.�„a .,.si City <br /> 1� <br /> Contractor's Name _1) _ L_. License Phone L <br /> TTPR OF WORK (Cheat). KEW WELL l-T DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> P110 INSTALLATION /�] PUMP REPAIR IR7 PUMP REPLACEMENT <br /> Other / f <br /> DIST&gCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL. FIELD CBSSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> M Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of GroutC . <br /> Other _ Other Infoxnation <br /> Lw <br /> I'M INSTALLATIONs r Contractor i <br /> Type of Pura H.P. <br /> PRiW ZFLACCHWt L7 State Work Don# <br /> : fit $9498 Work DOM 10111,( ` <br /> ,1L4 r A&, <br /> , '1Ci3,CtLON OF WELL: Well Diameter � App. ximate Depth <br /> Describe Material and Procedure <br /> I bere4"a,gree to comply with all lags and rej-u-1itions of the San Joaquin Local Health Diatric <br /> and -thae State of California pertaining to or regulating well construction. Within FIFTEEN DA <br /> after completion of my work an a now Well. I will furnish the San Joaquin Local. hsalth Dietridt: <br /> WELL DRITLRAS REPORT of the well and notify thus before putting the well in rhe a <br /> iafornstion is true to the b"t of my knowledge and belief. . lio1awp <br /> SZGSBD 12 In. �u,) TITLE „ <br /> DRAWW1 E 8I0 <br /> vOR DRPARTMW NI313 ONUT <br /> E I01 <br /> t CATION ACCEPT® BY DATE /1' y- <br /> AOiIIxIOIW. emos B s <br /> ?WE II GROUT INSPECTION. INX S ION <br /> IN3P9CTION By DATE <br /> CALL. L 'OA A GROUT I2N,SPECTI(M PA,IOR To GROUTING AND PIS); :LA=IC G <br /> E H 1426 71/72 IM <br />