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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For. OFFICE: USS.: 1601 E. Hazelton Ave. Stockton,Stockton, Calif. <br /> Telephone: (209) 466-678.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 �� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued �7S <br /> :*. (Complete In Triplicate) 2-o3 - [?4,D-.93 <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. 1.862 and the Rules and Regulations of the. San Joaquin Local Health District. , <br /> JOB ADDRESS/LOCATIONG"o2NC/CLk-�O�( NG CENSUS TRACT <br /> Owner's Name r%­�Zoo-r�t� - - _ Phone 5 <br /> qq <br /> Address <br /> --1i4� 'C�.1 0 . D� <br /> r City ' <br /> F <br /> Contractors Name 11�C� Licensed Phone <br /> + "TYPE OF WORK_(Check):- `NEW-WELT. -//—DIEPEN-'/-/-'RECONDITION-/=/t `DESTRUCTION*, <br /> PUMP INSTALLATION/" PUMP REPAIR "/ / PUMP REPLACEMENT 17 <br /> other ,/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <'PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ITYPE OF WELL CONSTRUCTION SPECIFICATIONS ; vi <br /> Industrial I Cable Tool Dia. of Well Excavation i <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> �! Irrigation 711 � Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grout <br /> Other Other Information <br /> d�PUMP INSTALLATION Contractor � 6A 0IJ � S"yf3 /l!4 . 6 & 60 �' y `���'" f: <br /> Type.of PumpH,P. <br /> PUMP REPLACEMENT: / / State Work Done <br />" PUMP tEPAIRs / / State Work Done <br /> OF,-TPUCTION OF^WtLI : Well[Diame ter Appr.oximate.:Depth. q <br />`i <br /> Describe Material and Procedure <br /> i� I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distric <br /> and the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAY <br /> 1` after completion of my work on a new well, I will..furnish the San Joaquin Local Health Distric <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the st of my owledge and belief. <br /> SIGNED -0 TITL H/ <br />:t tA01DRAW PLOT PLA14 ON REVERSE S E) <br />-a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE Z r <br /> 4' ADDITIONAL COMM1ENTS: 1 <br /> PHASE 11 GROUT qNSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> g F u IA9A 5/731M <br />