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V1j <br /> SAN JOAQUINyLOCAL HEALTH DISTRICT <br /> 'OF.-OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s��a LJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Disprict. <br /> JOB ADDRESS/LOCATION L1 L/ O AP IL. T CENSUS TRACT " <br /> i <br /> Owner's Name 130 Phone j3O <br /> Address L!IV y D City ' <br /> Contractor's Name l License #2S-,o/&3 Phone " 4 yO' <br /> TYPE OF WORK. (Check) : NEW WELL DEEPEN -/-7 RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT !XT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK '7 SE14ER LINES PIT PRIVY O <br /> SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> - i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria]. 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 S' <br /> Other , Rotary Type of Grout <br /> Other Other Information <br /> -.z-C,s 76 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. -r. <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ?F9TRUCTION 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 /> � <br /> SIGNED 4 ,14,L.L � TITLE e 4e <br /> (DRA LOT ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PI I <br /> A /6, DATE 17/W <br /> APPLICATION ACCEPTED .BY �• �� <br /> ADDITIONAL COMMENTS: <br /> PHASE I° GROUT INSPECTION PHASE IIT INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> L-..GALL F'OR.. "�ROi3T INSPE TIO PIRO�t.. O .GROUTING AND..FINAL INSPECTION. 7,. .�-_._. a ,w <br /> » 11 � 1 n r q/7! 3 1-M <br />