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SAN JOAQUIN LOCAL HEALTH DISTR- - <br /> I-rUT OFF E USE: lbdl E. Hazelton Ave. , Stockton, OQfif. <br /> _ Telephone: (209) 466-6781 <br /> f_ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 3 <br /> i I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -16-93 <br /> (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 made in compliance with San Jbaqui: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��Y' �j(/{J qGj CENSUS TRACT <br /> Owner's Name i—a"J &T �f Phone <br /> Address 5117 plc. City 5� <br /> Contractor's Name License # Z, hone <br /> TYPE OF WORK (Check) : NEW WELL / / EEPEN /-7 RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other f-1 <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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor J lT <br /> — -- - <br /> Type of Pump c r H.Y. ,/ <br /> PUMP REPLACEMENT: 5/ State Work Done crm®�B t2 Q 40/� ! i�. � p �e i( /Vex) <br /> PUMP UPAIR: / / State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> WELL DRILLERS REPORT of the well and notify t em be o utting the well in use. The above <br /> information 's true to the best of my wle and bels f. r <br /> SIGNED/ 11i LE /RS.� <br /> (D T PL N RE SE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I p <br /> APPLICATION ACCEPTED BY /- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IZ OUT INSPECTION PHAS jjI/FI7jAL INSPECTION <br /> INSPECTION BY �y� _ DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 - 5/731M <br />