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x" r+ `� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,s2- //�4/ <br /> 7z-/��� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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/LOCATION 4i+^-M,aj1A A) 7, p d7 Va hll k`.v,& iJf 41,4j c4 &&y!2,:u-r AL&4PENSUS TRACT <br /> Owner i s Name S' C tj U (;'e Phone Z e,-f <br /> Address i Z 10 1V- jL LA 11 H City M AV -1 a <br /> Contractor's Name i; ,, ,Aj- Dr License #/gLZd Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION /`7 <br /> PUMP INSTALLATION _.N PUMP REPAIR / / PUMP REPLACEMENT f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK o a i SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia. of Well Excavation S-0., lL � r� <br /> �( Domestic/private Drilled Dia. of Well Casing ra.j 0 <br /> Domestic/public Driven Gauge of Casing 11 �7 <br /> Irrigation Gravel Pack Depth of Grout Seal s o ' <br /> Other Rotary Type of Grout C,V-r- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor t(,Alf 11,68V A t " <br /> Type of Pump H.P. 'ro <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,)ESTRUCTION- 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 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 13,�,Vt 1TLE <br /> (MAW PLO LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL_INSPECTION <br /> INSPECTION BY DATE �! '7.3 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> + , E H 1426 7/72 1M <br />