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SAN JOAQUIN LOC}L TH DISTRICT <br /> FOR- OFFICE USE: 1601. E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone: (204) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2-''5 I <br /> THIS PERMIT EXPIRES. I YEAR FROM DATE ISSUED Date Issued (,- ,5-:z <br /> (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 /> JOB ADDRESS/LOCATION 7 17 S C - ) CENSUS TRACT <br /> Owner's Name10 At f Phone �G <br /> Address 1/97 T . Gnl6 j'_ City <br /> Contractor's Name G G. License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/ RECONDITION /� DESTRUCTION /_7 <br /> PUMP INST LATION / / 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 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. 1§_6 Ll <br /> Other T�Otary Type of Grout _�__ '4"A --/y <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 70 134F M12VC,,V S -3 p 1 15,11_ 90pfP . C6, <br /> Type of Pump � U/3%'4/�/l'3/ .Z F _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work none <br /> ESTRUCTION OF WELL: Well Diameter �e Approximate Depth �Q <br /> Describe Material and Procedure <br /> C,�5 <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 /> �-- i <br /> SIGNED TITLE <br /> (DPW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: �i�(C,B ,�,:� o f4/-7.- <br /> An <br /> � re-Al <br /> PHASE II GR4OU INSPECTION F SE II /FINAL NSPECTION <br /> INSPECTION BY DATE `_ ' INSPECTION BY�. &I DATE 9 f1 )2. �T <br /> CALL FOR A GROUT INSP CTION PRIOR TO,�',ROUTING F!N�L INSPECTIO � <br /> J <br /> pA, l E H 1426 0 �n a 3- e�s�/�� �..0 �r�t <br /> .rc..l.0 ,.rx�.�o-i <br />