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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE-t-'' ' . /1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION` OR PUMP PERMIT Permit No. 5 <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued- <br /> (Complete In Triplicate) <br /> Application is hereby-made- toy the San Joaquin Local Health District lor 'a permi-t -to construct <br /> and/or 'install the work herein described. This application is made .in compliance. wiih San. Joaqui: <br /> County Ordinance No. 1862 and the Rules and' Regulations of the' San Joaquin 'L6cal Health District. <br /> CENSUS TRACT Oft­2-vD-0--- <br /> (?rAmer',s. Name kaki `` Phone <br /> 191 <br /> Address 2 o q 7 L'crc-.1Zz1 d-vC - -.. -- -- - City - 10c is -- <br /> Contractor's Name Ash ley L'� ��,��c,s�,�� License # 527234>3 Phone 7-1 s"7 <br /> TYPE�OF WORK --(Check)-: NEW WELL DEEPEN /_7 RECONDITION /? DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL ° CONSTRUCTION SPECIFICATIONS <br /> Industrial s Cable Tool Dia. of., Well Excavation <br /> X Domestic/private Drilled Dia. of, Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S^G 4 4 -_ <br /> Other Rotary Type of Grout <br /> Other Other '.Information <br /> PUMP INSTALLATION: Contractor Ki+g�/,f�,� G. �1a+�c�l� d. S�r•� <br /> Type of PumpFa I;, 9 b H.P. <br /> PUMP REPLACEMENT: r/ / State Work Done <br /> PUMP REPAIR: / ./ State Work Done E <br /> :,:DESTRUGTION OF WELL: Well Diameter-4 :,. a. -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 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 /> SIGNED TITLE ` <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P E I GROUT .INSPECT 0 P III/FINAL INSPECT IO <br /> INSPECTION BY DATE INSPECTION BY TE <br /> CALL FOR A G OUT.INSPECTION PR OR. TO GROUTING AND FINAL :INSPECTION. <br /> E H 1426 <br />