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' SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> tR , r�CE USE: 1601 E. Hazelton Ave. , Stockton, Calif.' �R�`�4 <br /> Telephone: (209) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby.made: t�o 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 6311 Y,,=h. Rd._ Tr CENSUS TRACT ' <br /> Owner.'s Name Mary T nnign Patiijn Phone ' 213-4,W6-46391_ _ <br /> Address lllf Saticofr Sign ffa Cal - City Sun Vallrlar Cali, <br /> __.. , <br /> Contractor's Name 4,3�1hI 5 �TO. f = License #&�3zZ Phone <br /> TYPE OF WORK (Check) : NEW WELL , / DEEPEN '/ / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / I PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGTISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public ' Driven - Gauge of Casing <br /> Irrigation i Gravel Pack Depth. of Grout Seal <br /> Other x_ Rotary Type, of Grout _ <br /> 3 Other- ,,.. oi0ther Information .�- <br /> PUMP 'INSTALLATION: Contractor <br /> _.�. Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done `:_'__ <br />,. DESTRU_CTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure s F, <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 /> .f <br /> SIGNED TITLE e l-,-14� <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r. " DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I /F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />