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S,+N JOAQUIN LOCAL HEAL'T'H DISTRICT (� <br /> 1601 E. liazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 7J- 75. <br /> 7 f' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date ISSUL-d <br /> (Complete In Triplicate) <br /> ,'.n;)lication is hereby ;tide to the San Joaquin Local Health District for a permit to consti i;, t <br /> /or ins�:al the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1362 and the Rules and Regulations of the San Joaquin Local Health District. <br /> J03 ADDRESS/LOCATION ,� - %//�>�+�j /,Z V/ ,,,oes,--f4,e+To?UENSUS TRACT <br /> Owner's Name <br /> yoflli�t��[G�se Phone <br /> Address / Cityzr.; Vtl�� <br /> Contractor's Name _/ 4CK �2 1 License <br /> TYPE OF WORK (Check) : NEW WELL _( DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION � PUMP REPAIR / / PUiiP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA:rK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I�1'1'l,^iDI;D 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 /> Pl 22 INSTALLATION: Contractor , /CC9G C- <br /> Type of Pump c 3"��6 P�.k.'�6/G-' H.P. / Wil/ <br /> i'U"-Ll° R1 21-ACT's ;EN'I : ! / State Work Done <br /> PUMP '�.L'PAIR: / / State Work Done <br /> DFgTRUCTION OF 'i:dELL: Wel]. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ropy are t.o coi�;ply with all laws and regulations of the San Joaquin Local Health District <br /> aid ti1� Stag of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ::Lcr con<<letion of ray work on a new well, I will furnish the San Joaquin Local Health District a <br /> :LL Di.ILLL'RS P.:. ' of the well and notify them before putting the well in use. The above <br /> i;uorr:atiop i tru6 to f my nowledge and belief. <br /> TIT , !('aF. <br /> DRAW PLOT PLAN ON REVERSE. SIDE <br /> FOR DEPARTMENT USE ONLY <br /> l' • , DATE <br /> BLJ 3 <br /> 1GI:OUT Iyls` ( Z PHA III FINAL INSPECTION <br /> INa:?;:CTION Ly DATE(. 1 INSPECTION L'1' a`r't; DATE <br /> A GROUT INSPE1,GTIO,N Pi:I( is TO GROUTING AND FINAL INSPECTION. <br /> �/ T�1M <br />