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w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E £. OPFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. 7y-Sp�j <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /6 '�/-1 y <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 Ido. 1862 and the Ruses and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION AlL-' G CENSUS TRACT <br /> Owner's Name A I S / (-As_ T— Phone 3 ig <br /> Address L City 4-opt C A e-/l= <br /> . --! A4T <br /> Contractor's Name LL <br /> Z -.1£RS.'�Ie,614S7 � l�4Phone <br /> TYPE OF WORK Check-: NEW WELT, DEEPEN '/—/_ RECONDITION_ ' DESTRUCTION -- <br /> � ) /� / / <br /> PUMP INSTALLATION _W PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT foo " OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia. ,of Well Excavation 1,4 <br /> Domestic/private Drilled t Dia. of Well Casing <br /> Dome tic ublic Driven ' Gauge of Casing Ep � - <br /> Irrigation Gravel Pack Depth of Grout Seal �� <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Z!$'7E <br /> Type of Pump H.P. '3 d <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / J State Work Done <br /> .DFSTRUCTION OF. WELL: Well Diameter Approximate Depth. <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 of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new wells I will 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 best of my knowledge and belief. <br /> SIGNEDITLE <br /> (MV& PLOT AN ON REVERSE SID <br /> ( ';'FOR DEPARTMENT USE ONLY *� <br /> .PHASE I vs; 1 <br /> APPLICATION -ACCEPTED %BY Z <br /> i�-C DATE %Q <br /> ADDITIONAL COMMCNTS <br /> I : R UT INSPCI PSE III/FINAL INSPECPHAS TION <br /> INSPECTION BY DATE INSPECTION BY DATE .. /111 7.} - <br /> 1 - :_ <br /> CAI,-L•-�'OR--,4-GROUT•-INSPECTI-ONaPR-IOR TO--GRO TING..AND­FINAL INSPECTION. <br />