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e6 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£. 61 ICL" USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Ll_ a C <br /> T,P- ?-,Y3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/orj. r Ball the work herein described. , This application is made in compliance with San Joaquin <br /> Countl Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District, � <br /> JOB ADDRESS/LOCATIONON IA4C cf� �7RoN� E- �,�f'A'flt. <br /> Owner's Name phone <br /> AR ! 'Apt-IPA RVR S —wA Yffy <br /> Address City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION / / DESTRUCTION /7 <br /> _ _ a <br /> PUMP INSTAL TION / / PL'Mp REPAIR /—/, PUMP REPLACEMENT /- <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I <br /> SEWAGE DISPOSAL&V_IELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria4r- Cable Tool Dia. of Well Excavation o� <br /> Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public Driven' " Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal /e - <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: ~ Contractor s G f 7 C. 0 <br /> Type of Pump H.P. <br /> _ '7J?brtl 'yf� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / State Work Done <br /> ,DFSTRUCTION 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 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 /> 14ELL 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 /> SE SIDElow <br /> FOR DEPARTMENT USE ONLY <br /> PtiASF I <br /> APP <br /> "-TON ACCEPTED BY i DATE <br /> t COMMENTS: <br /> PHASE II GROUT IQ PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ �' , DATES <br /> '1UT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />