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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr.:OF'FICE ISR: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION Olt PUMPrpEBftIT e M NtNo. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r=Zg_;;�3 <br /> it (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 Joaquin <br /> County Ordinance .No. 1862 an4 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I0 O r CENSUS TRACT ' <br /> Owner's Name �'Zak __ I SH Apo "Tr"` <br /> Phone <br /> Address 1200 <br /> B� <br /> � City. . �• ��� <br /> Contractor's Flame �. V" License # j s hone �� <br /> TYPE OF WORK (Check): NEW WELL'/—/ DEEPEN j-7" RECONDITION-/_7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR'& PUMP REPLACEMENT /7 <br /> Other}/ / — <br /> x <br /> DISTANCE TO NEAREST: SEPTICjj TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP(_QL/SEEPAGE PIT OTHER <br /> , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION$ <br /> Industrial * Cable Tool "' Dia." of Well Excavation- �. <br /> Domestic/private t Drilled .. Dia.' of Well Casing O <br /> 'Domestic/public 1 Driven' Gauge of Casing <br /> Irrigation E Gravel Pack Depth of Grout Seal <br /> Other Rotary _ Type of Grout <br /> t Other Other Information <br /> i <br /> PUMP INSTALLATIOid: Contr'ictor <br /> I.s�t •'x . <br /> M Type of Pump ` <br /> PUMP REPLACEMENT: <br /> /'/ State`;Work Done n <br /> PUMP 'REPAIR: " luJ ,„ State Work Done <br /> We <br /> .DFGTRUCTION OF WET.L: Well Diameter -i�--�% <br /> - Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all- laws and regulations of the. San Jo quip Local Health District <br /> and the State of California pertaining to or regulating well '•const twin Within FIFTEEN DAYS <br /> after completion of my work on a neva 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 /> informatio true to the bek st of my kno -ledge and -belief. <br /> SIGNED �cJGT <br /> -ITLE <br /> (DRAW PL 'I"PLAN�ON I2E7 SE SI E) ' <br /> PHASES DEPARTMENT i15E ONLY ` <br /> APPLICATION ACCEP''?:D B ' DATE �� <br /> ADDITIONAL COMMEt; 'ti; ` <br /> PI-ASE' II GROUT INSPECTION Wy <br /> *AT.NSPECTION <br /> INSPECTION BY DATE INSPECTIO <br /> •r <br /> ••CALL FOR A GRGJ'i' -INSPECTION PRIOR TO..GROUT ING,AND -FINAL <br /> E H 1426 <br /> t</71 <br />