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SAN JOAQUIN LOCAL HEALTH . <br /> DISTRICT <br /> IOF. Off:l E tlSSt 1601 E. Hazelton Ave. , Stockton, Calif. _i <br /> ±g` 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 ate 7� <br /> I (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 herein described. ' This application is ma& in compliance with San Joaquin <br /> i` County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION f d/,I c?6 -Al !J["T V E R- p CENSUS TRACT <br /> Owner's Name Ado"l- P A/ 4-c-N Phone 6 <br /> Addressy 7U Al ee-f<M A "N R. D - city - L, n 4)/ C d z-/.f <br /> Contractor's Name A_JA '7- ----- License kZPhone k4,ra <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / f PUMP 'REPAIR I I PUMP REPLACEMENT <br /> Other:./ / <br /> DISTANCE TO NEAREST: SEPTICTALK G j"` SEWER TINES PIT PRIVY <br /> SEWAGE' DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -� <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONST <br /> Industrial I Cable Tool Dia. of Well Excavation jC / <br /> Domestic/private Drilled Dia. of Well Casing; <br /> Domestic/public Driven Gauge of Casing ! Z <br /> Irrigation Gravel Pack Depth of Grout Seal Le� <br /> f Other x Rotary Type of Grout <br /> Other Other Information <br /> C <br /> S";;14 4, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. -2� <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> .DF.RTRUCTION,OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procediure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> E and the Stare 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 thelwell and notify them before putting the well in use. The above <br /> information is true to the Vest of my knowledge and belief. <br /> t <br /> TITLE <br /> (DRAW PLO PAN EVERSE SIDI) <br /> FOR DEPARTMENT USE ONLY <br /> s PHASE I <br /> APPLICATION ACCEPTED BYr r !j� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii G OUT 'INSPECTIO PHASE III/"FINAL INSPECTION <br /> INSPECTION BY DATE � �_5' INSPECTION BY E DATE / <br /> CALL FOR A GROUT -INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />