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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> !Or..OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued - G-7 3 <br /> (Complete In Triplicate) <br /> Application is hereby made. to the San Joaquin Local Health District for a permit to construct <br /> rand/or install the work, herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance .No. .1862 and the ule-e and Regulations of the Sari Joaquin Local Health District, <br /> I t <br /> JOB ADDRESS/LOCATION -AL1i <br /> m4e_ 716ho CENSUS TRACT <br /> Owner's Name Ct f� �^,f fid ' Phone <br /> AddressCity .,r JCo Fi <br /> '�.�e7'rt vasal <br /> Contractor's Name t License -Phone -7424 <br /> Y <br /> . F a <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN /7 RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /R/ PUMP REPLACEMENT- 1-7 <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 �1 <br /> Domestic/public Driven Gauge of Casing <br /> �S Irrigation ' Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information r� <br /> PUMP INSTALLATION: Contractor �R . <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: '/x/ State Work Done <br /> ,DFRTRUCTION OF WELL: Well Diameters Approximate Depth E <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 m now and � lief. <br /> l <br /> SIGNED �v�� G/ ry. ITLE <br /> LOT. PLAN ON RE -FRSE SIDE)FOR DEPS ZTMENT USE ONLY <br /> PHASE I — <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COUNTS: <br /> PHASE -II GROUT INSPECTION PHAS II/F NAL INSPEC IO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 <br /> CALL FOR A GROUT INSPECTION ,PRIO.—TO GROUTING AND FINAL INSPECT ON. <br /> E H 1426 _ r� /7 j— <br />