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,p <br /> JOAQUIN LOCAL HEALTH DISTRIC'.t,,` <br /> !0F. 671TICE USL: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7S^�S-�o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued � -7 <br /> (Complete In Triplicate) <br /> Application is hereby ;Wade 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 Distriat., <br /> JOB ADDRESS/LOCA'TION . G/.? f.! - -VI I- S 0/j/ e!l/� CENSUS TRACT <br /> Owner's Name WA 9 Qw 7' / Phone 477 <br /> Address ro/Cc�.7-6 A V-G L, i 5 City ' 7'f��/ <br /> Contractor's Name <br /> License �� G5'7 % Phone fa"(,V_P6'3;X <br /> k <br /> TYPE OF WORK (Check) : NEW "WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR I I PUMP REPLACEMENT <br /> Other <br /> `DISTANCE TO NEAREST: SEPTIC TAI4K SEWER LINES PIT PRIVY <br /> y ,. <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 y: <br /> Irrigation Gravel Pack Depth of Grout Seal _ <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump " <br /> PUMP REPLACEMENT: IV Sate Work Done <br /> PUMP 'tEPAIR: Y / / State Work Done <br /> DFgTRUCT�ION OF WELL: Well Diameter Approximatd Depth <br /> ' ]3escribe 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 /> infarmation is true to the best of my knowledge and belief.p <br /> SIGNER /e TITLE <br /> (DRAW PL LAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> x PHASE I n <br /> APPLICATION ACCEPTED .BY QS D 'TE � Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO�iECTIOIV PHASE IIT/FINAL INSPECTION <br /> ! INSPECTION BY DATE INSPECTION BY 01 DATE 6.. <br /> - CALL-FOR-A GROUT INSPECTION PRION TO GROUTING AND FINAL INSPECTIO . -� <br /> E H1426 5/731M �.f <br />