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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0—FlO1'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. may_ 1p/ �U <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3,2 2, <br /> (Complete In Triplicate) 06 3 - (ra r- 0 9 <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 /> ,,_,J <br /> U c��p�t�.�r S � /y CENSUS TRACT <br /> JOB ADDRESS/LOCATION &72_ /`A '- --- _- <br /> Owner Is Mame _ <br /> /E /3JZatl F-LL / _ Phone 769-6-L69 <br /> Address /D0 /3�� i-z. 5' City G C�� <br /> Contractor's Name j� License #76.C761 Phone '41G 4 y�- <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPENm/ / RECONDITION / / DESTRUCTION /-'T <br /> PUMP INSTLATION REPAIR "//) PUMP REPLACEMENT /� <br /> AL <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 <br /> 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: Contractor 4 <br /> Type of Pump / H.P. . �Q . . <br /> PUMP REPLACEMENT: / / State Work Done <br />'PUMP-`REPAIR: ^ ` '• �;�y" State=Work�one� - � -�". _ _ __ � �,�� <br /> f <br /> ¢ ' Approximate De th <br /> ,DFTRUCTION OF WELL: 6Je11 Diameter App P , <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 /> i S <br /> SIGNED /� ��- e�� TITLE �"-� - <br /> (DRAW PLO LAN ON REVERSE SIDE <br /> 44 <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I I <br />'k APPLICATION ACCEPTED .BY DATE 3 12, i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOM PHASE III/FINAL INSPECTION ,f <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE(V-/- /r7, <br />'E CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> F 14 1 L 9 A. 5 . 731M <br />