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y Rw r Y <br /> V ' <br /> SAN JOAQUIN LOCAL AEALTH DISTRICT <br /> FOE:OFFILE USE: 1601 E. Hazelton Ave. Stockton, Calif. <br /> Telephone: (209) 465-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT hermit No. <br /> THISPERMIT EXPIRES I Y AR FROM DATE ISSUED Date Issued /-2/--7� ! <br /> — (Complete InITriplicate) <br /> Application is hereby made to the San Joaquin Loc4l Health District for a permit to construct <br /> and/or install, the work herein described. - This a0plication is made in compliance with San Joaquin i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �, e /7 R/ �` CENSUS TRACT - <br /> Owner's <br /> RACT .Owner's Name �/ <br /> I'!EP te�F- '-•-c.NOR A4 4.Al.1L.._ Phone �l��_"�04�?l 2, <br /> Address A"-1, 1 C C �- <br /> Contractor's Name s _ License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ RECONDITION / / DESTRUCTION /�' <br /> PUMP INSTALLATION / / PL REPAIR /—/-PUMP REPLACEMENT <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TLNK ' SEWER LI ES 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 <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal v <br /> Other Rotary Type. of' Grout \[� <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor - --- <br /> Type of Pump _ <br /> H.P. <br /> PUMP REPLACEMENT: � State Work Done <br /> 'UMP TtEPAIR: / / State Work Done <br /> ,DF. TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 ''constructiou. 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 TITLE � -�ty�r� <br /> (DRA LO PL ON REVERSE SIDE) �' r <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED .BY DATE 1-al- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASIJ/XKNAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY DATE e 2All <br /> L '? <br /> -CALL. FOR-A-GROUT-•-INS,PECTION-PRTOR-TO• GROUTING- D FINAL- INSPECTION. <br /> rf /7'1-j <br />