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oy <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 .a0 ICE USE: <br /> .11' 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> �= _ �E Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-,?- .597 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> ' i (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 workj�herein described. ' This application is made in compliance with San Joaquini <br /> County Ordinance No. 1862 and e Rules and Regulations of the San Joaquin Local Health District. <br /> rLy1_A) AZ- CENSUS TRACT <br /> JOB ADDRESSJLOCATIflN. 40 dt���-� 441-4 _ i <br /> Owner's Name �'!� ��!�h' FG��E-S Phone '//S- <br /> 3.7/-1264 <br /> — Exr 4-9eo pp <br /> Address 95 4 emtEl City O ' ,,91 TO f <br /> Contractor's Name .r U �G, License # GG[3 Phone <br /> {� <br /> TYPE OF WORK (Check): IEW WELL -/. / DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> . 'UMP INSTALLATION / / PUMP REPAIR / / ;PUMP REPLACEMENT /_7 <br /> .`Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> rIlI <br /> INTENDED USE ;i TYPE OF WELL CONSTRUCTION 5PECTFICATIONS <br /> Industrial Cable Tool { Dia. of Well Excavation <br /> i <br /> Domestic/private Drilled Dia. of Well Casing IN <br /> Domestic/public , _ Driven Gauge of Casing <br /> Ir.ri.gation. <br /> Gravel Pack Depth of Grout Seal <br /> other _ -I�- Rotary Type of Grout <br /> i� Other Other Information <br /> PUMP INSTALLATION: ' Contractor <br /> Type of Pump H'P. . <br /> PUMP REPLACEMENT: j / State Work Done <br /> PUMP, 'tEPAIR: / / State Work Done-. r <br /> ,DF-,TRUCTION OF WELL: Well Diameter `"` " Approximate Depth <br /> ,Describe. Material and .Procedure <br /> I hereby agree to ompiy 1 a f laws and regulations-of _ he__San�J quip LocAl Health District <br /> and the State of Calif <br /> pertaining .to or regulating well';construction. Within FIFTEEN DAYS <br /> after completion of my;I3work on a new well, I will. furnish the -Sail Joaquin Local. Health District a <br /> WELL DRILLERS REPORT o .the well and notify them before putting the well in use.; The above <br /> f <br /> information is true tojthe ..best--of_my_knowledge.and:.-belief <br /> SIGNED(�2 TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T DATE <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: <br /> PHAS Il ROUT INSPECTION P94SE _ftI11FML INSPECTION <br /> INSPECTION BY DATE ..Z 3 INSPECTION BY DATE1111174— <br /> i CALL FOR A GRO <INSPECTION PRIOR TO GROUTING,AND FINAL INSPECT ON.p� <br /> E H 1426 �N 5/731M / <br />