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�G <br /> I' 1 SAN .IOAQUIN LOCAL HEALTH DISTRICT <br /> Oi'ii( E Uyl✓ 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. REAR FROM DATE ISSUED Date Issued/ <br /> (Complete In Triplicate) <br /> Rpplicacion :is hereby -made to the San Joaquin Local Health District for a permit to construct <br /> rind/or install the work herein described. ' This application is made in compliance with San Joaqu;: <br /> Founty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District, <br /> JOB ADDRESS/LOCATION _? �� - / �= —_"- _ CENSUS TRACT <br /> j)mer's Name ' / a� � =�"►��_._ - -- Phone 146 c, -G e*4, <br /> Address 3 S' City 9 T/r'A/ <br /> P"ontractor's <br /> Name n C-0- License # z71,je,3 Phone 44.7-713 j,­tom' <br /> F1_1`YPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /A PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> --DISTANCE TO NEAREST: SEPTIC TANK 7,0 ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ! „ <br /> f,, Doitestic/private - Drilled Dia. of Well Casing <br /> { Domestic/public Driven Gauge of Casing i i- <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout Gau <br /> f Other Other Information < . c�. �l3� <br /> r'i MP INSTZILLATION: <br /> Contractor /y. _� n , z 5-7 7 <br /> Type of Pump H.P. <br /> U9' RLPLACMI NT : / / State Work Done <br /> 1 <br /> +PUMP 'REPAIR: .. / / State Work Done <br /> . r — <br /> L)FgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> � hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i `Lnd the State of California pertaining to or regulating well construction. Within F'IFT'EEN DAYS <br /> :after completion of my work on a new well, I will furnish the San Joaquin Local 'He.alth District <br /> k' LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> n ormation is true to the best of my knowledge and belief. <br /> IGNFI) .iL�iz%�t �. �PL• sTITLE <br /> { - (D W PLOT <br /> AN j0 REVERSE SIDE) <br /> _= FOR DEPARTMENT USE ONLY <br /> P iiAS E I � ��, ��� <br /> _PPLICA`T!ON ACCEPTED BY � i DAT <br /> IE f <br /> .ADDITIONAL CONLDI'X S: <br /> n1d'f <br /> �. 'L..i�aa.La c Jr•. t,:--,� .:�4 i. �_+.s...,_z.��.,..6.. ,��`-L_r.da.i"�',>.- "� .��I.,�k.�ua:.ir�"ur�.`�,�:�� sa:,.s+Qs-.3�� ';. sk }�`_ <br />