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�v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For.'.* FICE USE: 1601 E. Hazelton Ave., Stockton, Calif.. <br /> Telephone: (209) 466-6781 q� 7r� <br /> APPLICATION. FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. F <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 'i and/or install the work herein described. ' This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .2 G �" C O PRAM o 190111' R D CENSUS TRACT <br /> Owner's Name — Phone <br /> Address /9Ga-G E �PPrAaLJS 2d city ^ ^i�� �/ <br /> Contractor's Name License 92jS74/ Phone uG4983,4; <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN/_7 RECONDITION / J DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other ./7 <br /> DISTANCE TO NEAREST: SEPTIC TPaNK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <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 n <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> C <br /> c <br /> ' PUMP INSTALLATION: Contractor e.�.._,>.,.��_ H.P. � � <br /> Type of Pump <br /> } .PUMP REPLACEMENT: State Work Done - C <br /> t _ s <br /> PUMP REPAIR: / / State Work Done <br /> 2 <br /> Approximate Depth <br /> ,DF'zTRUCTION OF WELL: Well Diameter G <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 /> 3 WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> a information is true to the best of my knowledge and belief. <br /> / TITLE <br /> SIGNED <br /> (D p p ON REVER <br /> SE SZD <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> APPLICATION ACCEPTED .BYC`ya= ��� DATE <br /> r� 75^ <br /> ADDITIONAL COMMENTS: // PHASE II JFINAL INSPECTION <br /> PHASE 12 GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 573 <br /> E H 1426 <br />