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SAN JOA UIN LOCAL HEALTH DISTRICTyl��y <br /> I.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 73- 375111 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7f—m-360") <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued -lam <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 No. 1862 and the Rules and Regulations of the- San Joaquin Local: Health District. <br /> JOB ADDRESS/LOC TION CENSUS TRACT <br /> J _ <br /> Owner's Name �! E n V I-t,S Phone <br /> Address 2. d 3 --� City <br /> Contractor'"s Name ki It-la -)-d License # �� 3IZPhone.F7_2, S 6 <br /> i <br /> TYPE OF WORK (check) :�TNEW WELL.. DEEPER '/_ RECONDITION <br /> PUMP INSTALLATION / PUMP REPAIR ,/ / PUMP REPLACEMENT /_7 <br /> Other I / <br /> DISTANCE TO NEAREST: SEPTIC TANK .fE_(3SEWER LINES PIT PRIVY Na <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 /> Domestic/private Drilled Dia. of Well Casing ` <br /> Domestic/public Driven Gauge of Casing 9 <br /> Irriga 'on Gravel Pack Depth of Grout Seal <br /> Other_ ,� Rotary Type of Grout y <br /> "�""4 Other Other Information ' <br /> f�L et0,0 e✓✓Qk s e <br /> PUMP INSTALLATION: Contractor Al 4 a -it ! ix ex-, S <br /> Type of Pump .: B . H.P. <br /> i <br /> PUMP REPLACEMENT: / J State Work Done 1]I <br /> PUMP UPAIR: / { State -Work Done <br /> ,DFR'TRUCTION;OF WELL: Well Diameter Approximate Depth <br /> I Describe Material and Procedure I <br /> I hereby agre4, to comply with all laws and regulations of the San Joaquin Local Health' District <br /> and the4tiate of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after.,+completion of my work on a new well., I will furnish the San Joaquin Local Health' District a <br /> WELL,.DRILLERS REPOR of .the well and notfyathem before putting the well in use. The above <br /> in ormati is tr�r�ue lto-the-best-of_ my�knofaledge-..and' belie <br /> SIGNED 114 V lu - ! _4::,_-Y 1 - - G TITLE u � <br /> ?' 1T {DRAW PLOT PLAN ON REVERSE SIE <br /> FOR PARTMENT USE ONLY <br /> PHASE I # t <br /> APPLICATION. ACCEPTED .BY r ` ' t' DATE <br /> ADDITIONAL COMMENT: <br /> e <br /> PHASE,, II GROUT._IN„ ECTION `,, , PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 7-.16 INSPECTION BYDATE Q <br /> CALL.I'OR. A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL,INSPECTION. ' <br />