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(`N JOAQUIN LOCAL HEALTH DISTRIG, ) <br /> �. O1FiC USE: 1601 E. Hazelton Ave. , Stockton, Calif. f ` <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP rUODIbued <br /> Permit No. 7,�`` � j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISat Iss _—��zr <br /> I . (Complete In Triplicate) <br /> Application is hereby bade. to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. , This appli.Cation is made in compliance with San Joaqui, <br /> County Ordinance No. 1862 acid the Rules and Regulations of t `San Joaqu n L 1 Health District. <br /> .TOB ADDRESS/LOCATION Cry S�� �' 169 T N SU <br /> SU TRACT I <br /> Owner's Name Pay 19&-' 7" Phone26 e7,�f g <br /> Address Q� J�'J >Tom' Y. city .> .. <br /> Contractor's Name '�7 U A4 License G'7-3-?3 Phone q6?r- <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /- i <br /> PUMP LINSTALLATION J PUMP REPAIR J% PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Ln rw I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V, <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SftCIFICAZIONS <br /> Industrial. I Cable Tool' Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public t 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 <br /> Type 'of Pump R.p. <br /> PUMP REPLACEMENT: FT ;State Rork Done <br /> PUMP UPAIR: / / , State_Work..Done--.. _. <br /> v?.-TRUCTION OF WELL: Well'IDiameter 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 1 t <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> 1 {DRAW PLOT PLAN ON REVERSE SIDE) <br /> I FOR DEPARTNMT USE ONLYPHASE I <br /> 7 � <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL =D=ENTS; 1 <br /> PRASE II GROUT, INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY .:_ DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION' PRIOR TO GROUTING AND FINAL INSPECTION. <br /> T TT 9 /7 I <br />