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/ -'V JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160)omd. Hazelton Ave. , Stockton, Cal. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquir. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> / <br /> JOB ADDRESS/LOCATION ) 5/7V/1 /1/�, ��C-1jy/7 0 h�j'/� CENSUS TRACT <br /> Owner's Name qq < 4.Q 6;� Z P/ / i LL / JPhone <br /> Address d /7(�p to rC C'rrrra /Te ,/jur "2 City C-c <br /> �JfContractor's Name � / /�� t- /L License U /S7.r'oo Phone ,�f� .�G <br /> TYPE OF WORK (Check) : NEW WELL W DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_/ <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 /,7 " <br /> Domestic/private Drilled Dia. of Well Casing { .� <br /> X Domestic/public Driven Gauge of Casing /Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ X Rotary Type of Grout ap y 7` it <br /> Other Other Information <br /> P. 0, LfoX yPo 1Rgcy may, <br /> PUMP INSTALLATION: Contractor ( / % <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> _DESTRUCTION OF WELL: Well Diameter I 1-7Approximate Depth <br /> Describe Material and Procedure s •,� !�r / ry1J` /� o /� <br /> ,4t-//E�/rl �� /,�/,%l� G/J ..• "`.fit' Jiro <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Vealth 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 them before putting the well in use. The above <br /> information is true ttoo/the <br /> lQ�best of�jmyy knowledge and belief. <br /> SIGNED �Q /_%r!�rA !L /I�ILCY N TITLE Gk_ 1I16/�9k- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -1-42-7- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECiiON. <br /> E H 1426 4/72 1M <br />