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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOx_ O1 ICi: USE: 1601 E. Hazelton Ave. , Stockton, Calif. F <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued Al <br /> (Complete In Triplicate) Zoe-- O Z-V- 0�� <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 /> Q�.' ORT,# <br /> JOB ADDRESS/LOCATION ON 1�WA Saw7-H � M eFR�IVCJ- e�CENSUS�TRACT <br /> i <br /> Owner's Name -Xpk M /+RCT T Phone 4/634441_6 i <br /> oIF/=ic.e 9$2. _0914f y <br /> City , AF Z fi <br /> Address D f F. V <br /> Contractor's Name ! License #2 ,c;-7 G/Phone e4445P911,2 <br /> JL i r <br /> TYPE OF WORK (Check): NEW WELL DEEPEN 'I / 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,-J' Cable Tool 'Dia. of Well Excavation <br /> Domestic/private - - Drilled - Dia. of Well Casing <br /> Domestic/public Driven ' Gauge of Casing <br /> Irrigation ; Gravel Pack ,� `Depth of Grout. Seal <br /> Other Rotary Type of GroutRM <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 2 0 <br /> PUMP REPLACEMENT:, / / State Work Done , <br /> PUMP UPAIR: / / State Work Done <br /> ,DFIQTRUCTION OF WELL: Well Diameter Approximate Depth <br /> N Describe Material and Procedure <br /> f 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 thein before putting the well in use. The above <br /> s information is true to the best of my knowledge and belief. <br /> 4 <br /> SIGNED ve . <br /> < TITLE -- <br /> (DRAV POT PW OR REVERSE SIDE) <br /> I; FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATE tz <br />` ADDITIONAL COMLMEITTS: <br /> PHASE Ii GROUT INSPECTION P E I/FINAL INSPECT ON <br /> INSPECTION BY Ii DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL TNS TON. <br /> _ _. _ .-. q/731M <br />