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/11601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> USE: E. Hazelton Ave. , Stockton, Calif. <br /> b Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7 _ 6 o p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �0��z-'.S <br /> F (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 /> I <br /> G, JOB ADDRESS/LOCATION 7 C,�(,o �j a d rw �1 - - CENSUS TRACT <br /> 3 'Owner's Name l�✓1__ d�ri/ Phone <br /> I � .4o a m � � City . <br /> ' Address <br /> Contractor's Name ', � ,s 'y License # 1.i Phone _ �. -762 <br /> tA If <br /> 4W _ <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN/ / RECONDITION I_I. DESTRUCTION /_ <br /> E PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I7 <br /> Other ./ <br /> DISTANCE TO NEAREST: SEPTIC TA14K SE14ER LINES PIT PRIVY _ <br /> "SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE: OF WELL CONSTRUCTION SPECIFICATIONS <br /> �I <br /> Industrial. Cable Tool Dia. of Well Excavation - <br /> -- _ <br /> W, Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ---- _ _ <br /> Irrigation Gravel Pack Depth of Grout Seal ski <br /> ` Z <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> -Type of Pump -S H.P. <br /> PUMP REPLACEMENT: j / State Work Done <br /> PUMP 'REPAIR: State Work Done r d "toe' <br /> ,DFgTRUCTION 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 ox-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 o kn w.led e a belief. <br /> i <br /> SIGNED '\ TITLE �. <br /> W PtbT VLAN ON VVKRSE SIDE) <br /> . FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE �— <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/Fl?tAL INSPECTIOlk <br /> INSPECTION BY DATE INSPECTION BY DATE ?/ <br /> CALL FOR..A GROUT INSPECTION PRIOR TO -GROUTING AND FINAL ,INSPECTI- <br /> E H 1426 t - 5/731H <br />