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... . . , <br /> t ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 G <br /> APPLICATION FOR WELL CONSTRUCTION OR PU:4P PERMIT Permit No. 7 �E <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 1f-7 <br /> (Complate In Triplicate) <br /> Application is hereby ::,ndc to the San Joaquin Local Health District for a permit to constru;=t <br /> and/or install the wort: herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules a Regulations of the San Joaquin Local Health District. <br /> .IO$ ADDRESS/LOCATION, <br /> _ �'G� �d�Gf 160 �lOS IY .FAL <br /> CENSUS TRACT <br /> Owner'-s Name ! '</4 a lb C Li r S C,d Phone <br /> Address Ca $r/�l1\/( /mac _ .,,,.�.. —_ City <br /> Contractor's Name License Phone <br /> k <br /> TYPE OF WORK (Check); NTLW WELL / / DEEPEN /% RECONDITION /_/ �DESTRUCTION /_7 <br /> PUMP IXS ALLJAATION PUMP REPAIR / / PU., PIACEMENZ /? <br /> Utlzer +? / f— �� ' <br /> DISTANCE TO NEAREST:�30IC TANK SEWER LINES PIT PRIVY <br /> i SZ14AGE DISPOSAL FIELD" CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USz � TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industr-al Cable Tool Dia. of Well Excavation <br /> Dom"stic/private Drilled Dia, of Well Casing <br /> D s,estic/public Driven Gauge of Casing <br /> rigation Gravel Pac% Depth of Grout Seal <br /> Otoer Rotary Type of Grout <br /> Other Other Information <br /> r <br /> 13M1 INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PL:'4' REP LAC ,i;;iT: / / State Work Done 7� <br /> PUMP q.EPAIR: / / State Work Done �/�(S f ,�} �t.I r,-, P ,�f� S E — $��f4 <br /> DFs,TRUCTTON OF W2LL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby atirce to coa,ply with a°1 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 /> camp ie of my work on a new well, I will furnish the Sari Joaquin Local Health District a <br /> 11:.—L DRIE"I' as R.i�FRT of the well and notify them before ptitting the well in use. The above <br /> inforr7atlJi is t ;ae to the best of my knowledge and belief. <br /> SiCNF.D �LG�L4 ( TITLE _ <br /> (DWj PLOT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT L'SL ONLY _ <br /> i'ii :Sk: 1 <br /> AP! iG:T%ON ACC.";'T,:i� B'z _ DATE <br /> r`:DDITIO`AL CO <br /> .....,.,. +• - <br /> _ PHASE LNAL INSPECTION <br /> INSPECTION BY u!.T INSPECTION BY DATE <br /> CALL :0;� A CR0UT 1.1;§P:CTION Pi+i:•i� iQ C:ROUTING AND FINAL Ifi E ON. t <br /> ��2 5/731M <br /> .i <br />