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K z <br /> A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOF. OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z 5�--4uld <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7,57- <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 r? E C� I7 tt� CENSUS TRACT <br /> Owner's Name S d f L Phone 7 Z <br /> Address 77 U City <br /> Contractor's Name License #,j45--:ZQ Phone 6 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /� <br /> PUMP INSTALLATION / MP/ PUREPAIR/ / PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> DISTANCE; TO NEAREST: SEPTIC TLRK SEWER LINES PTT 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 M Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout. <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 146 H.P. S'¢ ,fry . <br /> i PUMP REPLACEMENT: i / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 5 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 />€ <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 a�l%oy.e <br /> information is true to the best of my knowledge and belief. <br /> SIGNED �IHTTLE c�14 <br /> - (DRAW PI;OTi,,PLAN ON REVERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> PRASE I r <br /> APPLICATION ACCEPTED BY � _ i�� 1 --J DATE / 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONN INSPECTI <br /> INSPECTION BY DATE INSPECTIO DATE <br /> CALL. FOR A GROUT INSPECTION PRIOR TO GROUTING AND FIN TO . <br /> E H, 1426 5/731M <br />