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II <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT A*gt,417 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �! <br /> Telephone: (209) 466-6781 7 3 -4 a 3 cJ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-Z. - �L�_7 {� <br /> is THIS PERMIT EXPIRES' l YEAR FROM DATE` .ISSUED Date Issued I-7 <br /> ' (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health. Distr,ict fora permit to construct j <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/LOCATION �f j d Al CENSUS TRACT <br /> E <br /> Owner's NamePhone //64_e o !�,3 <br /> ---— - <br /> i <br /> Address 3 g z S" G' ,�llc� � TT2// - City S �/eiV <br /> Contractor's Name5 1!-W_Z.d7 � . .,_...,,..., _ License #/9k$-o q Phone <br /> TYPE OF WORK (Check) : NEW WELL /K-DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /X' PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /7 x <br /> j! - <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES PIT PRIVY �! <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 11 �' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS LU <br /> ii <br /> Industrial 4 � � Cable Tool Dia, of Well, Excavation /Z" O <br /> X Domestic/private Drilled Dia. of Well Casing " <br /> Domestic/public 'I Driven Gauge of Casing <br /> Irrigation ! Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 41 ; <br /> A. Other _ Other Informatio -/yis <br /> .i <br /> PUMP INSTALLATION: contractor `911 <br /> Type of Pump H.P. <br /> ' • L li# <br /> II. <br /> PUMP REPLACEMENT: /g / State Work Done <br /> PUMP REPAIR: b / State Work Done lj <br /> J)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Deescribe Material and Procedure E JI <br /> I�. <br /> I hereby agree a to coin 1with all laws and regulations of the San Joaquin Local Health District ' <br /> S P Y' g q <br /> and the State •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 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 /> SIGNED i� 12 ^ ITLE <br /> H -_ (DRAW PLOT ON REVERSE SIDE :4 <br /> I <br /> it R DEPARTMENT USE ONLYAt <br /> } <br /> PHASE 1 Il 4 <br /> APPLICATION ACCEPTED BY DATE0E, <br /> ADDITIONAL COMMENTS: !I <br /> • PHASE j1,GROUT INSPECTION PHASE I. I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE S'7-3 <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. . <br /> 7 .72 lM <br /> E H 1426 .� � � / <br />