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k <br /> n SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: U 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUNK' PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued -/3 " -7 v <br /> (Complete In Triplicate) i <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 t; <br /> County Ordinance No. 1862 and. the Rules and Regulations of the San Joaquin Local Health District. <br /> 13�-►4"�l�,Mr�Rf� . - <br /> JOB ADDRESS/LOC i ONVAjV1911ejVCENSUS TRACT <br /> Owner's Name TP `Al Phone <br /> Address / / y' ©. E17- S-Li 8 V& City <br /> Canter's Name <br /> 'tT. Jam.,, `�✓TTG�_� !Sew License V Phone 518.-�7-,?r7 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ f RECONDITION DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR J;; _PUMP REPLACEMENT <br /> Other /-7 <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 C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information }� <br /> PUMP IIy'STALLATION: Contractor p <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP REPAIR: / State Work Done Sts -h _ rd, .i <br /> jr� T6tl <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> �4 <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 /> SIGNED TITLE f/-?, rAleiC <br /> (DRAW PLOT PLAN ON REVERSE SIDE) I�I <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I k <br /> APPLICATION ACCEPTED BY DATE. — <br /> ADDITIONAL COMMENTS: If f <br /> PHASE II G INSPECT P III/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M + <br />