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II SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> \APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS 'PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued2 <br /> (Complete In Triplicate) <br /> Rplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> d/or install the work herein described. This application is made in compliance with San Joaqui <br /> :ounty Ordinance No. 1862li _ and the 'Rules 'and Regulations of the San Joaquin Local Health District. <br /> B ADDRESS/LOCATION /61150 <br /> JJ i <br /> ,j=ai A i• �. c CENSUS TRACT <br /> honer's Name Phone <br /> ,dress . ) <br /> v City <br /> �ntractor's Name / 3 „7 w/ License # Aza. 3 Phone ( - zs__ <br /> II . <br /> �PE OF WORK (Check): NEW WELL / / DEEPEN /_� RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /1 / PUMP REPLACEMENT /—T <br /> Other <br /> TANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial i Cable Tool Dia, of Well Excavation W <br /> _ Domestic/private Drilled Dia. of Well Casing p <br /> Domestic/public j ' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> .I Other Other Information <br /> JMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. <br /> JMP REPLACEMENT: / 1I/ State Work Done <br /> Q /} <br /> REPAIR: .State Work Done ✓�e,oi/ [2c >-�n � �/ � l� s J �er aY�/7 �erQ:-- <br /> !�r <br /> iSTRUCTION OF WELL: Well Diameter A_Z� y/2"7 Approximate Depth <br /> D `scribe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of CalifornliA pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> r completion of my woik on a new well, I will furnish the San Joaquin Local Health District a <br /> L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> rmation is true to the best of my knowledge and belief. <br /> �l-ED ( T <br /> RWLAN REVERSESIDEp) <br /> yt <br /> E I <br /> FOR DEPARTMENT USE ONLY <br /> PLICATION ACCEPTED BY C\ DATE <br /> TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> PECTION BY j DATE INSPECTION BY . ��. DATErH <br /> L FOR A GROUT INSPECTION PRIOR TO..GROUTING AND FINAL INSPECTION. <br /> .1426 11 7/77 ,M r n <br />