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SAN 30AQUIN LOCAL HEALTH DISTRLGT <br /> FOI..,OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 9 ' <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED Date Issued/� -� <br /> (Complete In Triplicate) <br /> I� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct u; <br /> and/or install the workliherein described. * This application is made in compliance with San Joaquin <br /> County Ordinance No. 18b2 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION o O O H04&A R p R b CENSUS TRACT" <br /> i <br /> Owner's Name ARcaAtio A4fi9C-h1A11 RRes Phone 463,9790 <br /> Address AP City"S 74'Al Glf L/^ <br /> 9 00 D bWR2P <br /> Contractor's Name , License #z4S-7Cj Phone 46k,ass32 <br /> TYPE OF WORK (Check): * NEW WELL/ / DEEPEN '/% RECONDITION ( / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR I PUMP REPLACEMENT /=T <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 b <br /> Industrial _ Cable Tool" Dia, of Well Excavation <br /> WE Domestic/private' Drilled Dia. of Well Casing N <br /> Domestic/public Driven Gauge of Casing II <br /> Irrigation Gravel Pack i Depth of Grout Seal <br /> Otherl Rotary Type of Grout <br /> j Other Other Information <br /> i <br /> PLW INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done f <br /> PUMP REPAIR-' State Work Done 74-11' •-c ,' <br /> ,DFOTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to co ly 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 them before putting the well in use. The above II' <br /> information is true t°o the best of my knowledge and belief. <br /> SIGNED 9L�yGL d j�.,� �-*� TITLE -.A (iz <br /> i. (DRAW P PLAN ON REVERSE SIDES ? <br /> i FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PLICATION ACCEPTED BY / DATE <br /> " ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION H. /FIN INSPECTION <br /> INSPECTION BY---- p� DATE INSPECTION B DATE/� -'I <br /> i CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7 9 11.76 d 5/731M <br />