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SAN JOAQUIN LOCAL HEALTH DISTRIX" <br /> FOI:. OFFICE USE: 1'* . E. Hazelton Ave, , Stockton, CawIf-. <br /> Telephone : (209) 466-6781 �7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> J� ) THIS PERMIT EXPIRES 1 YEAR FROM DAT; ISSUED Date Issued <br /> (Complete In Triplicate) <br /> A licatio 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 Joaquin <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F <br /> JOB ADDRESS/LOCATION3Q6p 3 G//441s 1 CENSUS TRACT <br /> Owner's Name 171/I,1A,e).4C N/ �/9 XIS _ Phone �{�'�'7- S7 7 7 <br /> Address /� t�a� y / '�c FS7 6 <br /> c < 1 UPS' /!� ` S3S11 Cit CC <br /> 11 <br /> Contractor's Name %EW,,51�1- License 11 a3/)/j honev3/9-,S-) C' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION f-1 DESTRUCTION /7 <br /> PUMP INSTALLATION 0 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC TANKS _ Op SEWER LINES PIT PRIVY -� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 0 <br /> Industrial Cable Tool Dia. of Well Excavation 6\ <br /> Domestic/private Drilled Dia. of Well Casing " (N <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 6 A]F <br /> Other Other Information <br /> PUMP INSTALLATION: h Contractor ukv- <br /> Type of Pump ' k H. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 m.X work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS P T f t e well a l-ae, y them before putting the well in use. The above <br /> information i t ue o t of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY c/ {' IfDATE G 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA F Al. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � DATE (,-1-1Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP TION. <br /> E H 1426 4/72 1M <br />