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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For,:OFFIG8 use: 1601 E. Hazelton Ave; , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , D,4 7� <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 hererin described. This application is made in compliance with San Joaquin <br /> County Ordinance: No. 1852 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /5 ! N W(A/lJ50 CENSUS TRACT - <br /> ' L G. <br /> Owner s Name �—�-�LPhone-�A6�Lj�-13� - -- <br /> Address !S_ 1,/ o / Gf} <br /> - -- -7- 11�-_ !1�f� � � � .. Cit S 7 (/y <br /> Contractor's Name License #;26f*-,>41 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN "/_ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 0 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 I Drilled Dia. of Well Casing t1� <br /> Domestic/public 1 Driven Gauge .of Casing ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> _ = Other. Other Information <br /> } II <br /> 1 <br /> r 7 � <br /> PCMP INSTALLATION: Contractor <br /> Type of Pump . H.P. " y, <br /> .;Kra <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP UPAIR: / / State Work Done ; <br /> DFATRUCTION OF WELL- Well` Diameter s Approximate Depth i <br /> Describe Material and Procedure a <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California ..pertainiiig to or regulating well "construction. Within FIFTEEN DAYS E <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 />`t SIGNED TITLE <br /> (DFAV-PLOVIKAN ON REVERSE SID <br /> y'�: `}. ....ry FOR DEPARTMENT USE ONLY /0/3p'/> <br /> ,... ;-.. {/y.0. K�! d`l2...... DATE lU/ '/ . ...... <br /> P�3ASE I <br /> APPLICATION ACCEPTED .BY �. <br /> ADDITIONAL COMMENTS: 1' <br /> -PHASEII "GROUT (INSPECTION PHASE IIY/FINAL INSPECTION " <br /> INSPECTION BY , DATE. ;......INSPECTION BY DATE . :�5 <br /> CA4,L-k'b"--EdtOUT,..Il4SPECTZON-PRIOR-TO­GROUTTNG-AND-FINAL•INSPECTION.. <br /> E H 142G 5/731st <br />