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1�_Pd SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 151. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. Flo �� <br /> Telephone: (209) 466-6781 <br /> T APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2rg:��o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued <br /> (Complete In Triplicate) !LED—f O <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 /> � ' Wry- 7� Ta �74i�� c��rSus��� <br /> JOB ADDRESS/LOCATION 0>-L,,_ G' :S" T 1 *_¢ '` ` <br /> Owner's Dame A G(_OR 0 Al P 1 7C- Phone 4,4,V- 5—r-0-5— <br /> Address A 4e Calc A Y4- T To -- -_ - - city S 7/'Vi11 <br /> Contractor's Name f?0 SS !et1-L 14 4 NlLicense #? D 3_2 ; <br /> TYPE OF WORK (Check) : NEW WELL I( DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />� U1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />! Domestic/private Drilled Dia. of Well Casing /a <br /> I Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br />+ PUMP INSTALLATION: ContractorEG[s , .A1Xa.. <br />' Type of Pump H.P. '7/,a <br /> PUMP REPLACEMENT: / / State Work Done <br />' PUMP 'tEPAIR: / / State Work Done <br /> 3 :DFgTRUCTION 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 /> 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 �.c �-_ <br /> DRAW PLOT'PLAN ON REVERSE SIDw <br /> c <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYg:ZZ?g� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAVjjI6jINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' 76 <br /> - CALL--FOR-A­GROUT INSPECTION•PRIOR TO GROUTING AND FINAL INSPECTION. - _ _ - <br /> E H 1426 5/7311 <br />