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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R, F110 OFhoneF1ICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Tele <br /> p {209} 466-681 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 2--:1,7-7q <br /> i (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•N . 1862 and t� Rules and Regulations of the San Joaquin Local. Health District, <br /> � i <br /> .TOB ADDRE S/LOCATIW s00 F� �4� �� S <br /> cENsus TRACT S M <br /> Owner's Name n.PAX,, Phone <br /> Address lonl Af S-f-' w <br /> t City` rga <br /> — <br /> Contractor's Name #OwxWALL r}L V! P, CO. License ?_Phone <br /> S2 Z <br /> �=-- - <br /> TYPE OF WORK (Check) -NEW WELL . DEEPEN /_/ RECONDITION /_/ )DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PU1"fI''�REPi.ACEMENT /� <br /> . -Other, /-7 <br /> DISTANCE TO NEAREST: SEPTIC TAfVK SE LINES PIT PRIVY j <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER { <br /> INTENDED USE TYPE OF., WELL CONSTRUCTION SPECIFICATIONS I <br /> Industrial Cable Tool Dia. of Well -,Excavation Z �� <br /> Domestic/private i Draped Dia. of Well-Casing If � .' <br /> Domestic/public t. Driven Gauge of Casing zirj WA L.'- <br /> Irrigation ! IV Gravel Pack Depth of Grout Seal -5V r <br /> Other Rotary Type of Grout <br /> Other Other Information 0 Tg f} F <br /> i <br /> PUMP INSTALLATION: Contractor Q.VV <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done + <br />'=PtW—"tEPAIR: �....: / /'R.-State"Wzirk�'D ne •. «�. x - . <br /> t J a r <br /> .PFIRTRUCTION OF WELL: Well Diameter w Approximate Depth �. <br /> Describe Material and Procedure <br /> s <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Califorrniia 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 t e beft of my Xnowledge and belief. <br /> � A 3 <br /> SIGNER J�t") <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I // <br /> APPLICATION ACCEPT BY (' DATE <br /> ADDITIONAL COMMENTS; ezz 9 .% - I <br /> GROUT INSPECTION P S I INAL INSPECTION _ <br /> INSPECTION BY , DATE - INSPECTIO*-,B-Y DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GRX TING AND FINAL INSPECTION. <br /> E H 1426 e i7, ,.. <br />