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OAQUIN LOCAL HEALTH DISTRIC'.L.,` <br /> FOF.;OFFICE USE:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � .7 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District.. <br /> k <br /> JOB ADDRESS/LOCATIONLf 3 �3 - .N ���� U N aC�/� �/ CENSUS TRACT <br /> Owner's Name //,2 w o6q w 7 N /E-/Z Phone $6 4 <br /> Address TS A V City S 7/VN <br /> Contractor's Name License �� a�3-7L% Phone 4'C 4 <br /> ?,�ri/L��c-r� �,Q / ' z�- '. <br /> TYPE OF WORK (Check): NEW 'WELL / / DEEPEN 'f—/ RECONDITION /_7 DESTRUCTION /_7 4 <br /> Pme INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> _ .�.. <br /> Other <br /> 'DISTANCE .TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ` <br /> p SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �'fi: <br /> s <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ft <br /> Industrial Cable Tool Dia. of Well Excavation <br /> f — Domestic/private Drilled- Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing y: <br /> _ Irrigation Gravel Pack Depth of Grout Seal _ y G <br /> Other Rotary Type of Grout <br /> i <br /> Other Other Information c� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> { PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: - / / State Work Done <br /> a <br /> F <br /> DFgTRUCTION OF WELL: Well Diameter Approximatd Depth <br /> Describe Material and Procedure <br /> ? I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> j 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 to the best of my knowledge and belief. - <br /> :S SIGNEDTIT3 x <br /> r (DRAW PLOT`­PLAN ON REVERSE SIDE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I n <br /> APPLICATION ACCEPTED .BY QS DATEl 2' <br /> ADDITIONAL C0*Ei NTS: <br /> PHASE II GRO T FCTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY IDSA-TX <br /> -CALL-FOR-A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. G�►`� .� <br /> E H 1426 ._, _ , 5/731M _: <br />