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JOAQUIN LOCAL HEALTH DISTRTCV <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -— Telephone : (209) 466-6787. <br /> J APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 'L/- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 <br /> sn Rogul//atio((ns //of ��t��he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �r��fgQ f) )0/ .. - /b��Y /7 �f X11 r71 n2;p (l CENSUS TRACT <br /> Owner's Name _ /q/g11/110) /-//U!^'iy15' - 0iLr'f 5 4ei0S Phone <br /> Address /,_ (& �� 5 1-f/1 f^1CtM iez/. City X"i <br /> Contractor's Name _7,,,�n License ll LCl� SEX Phone ,5 ;?-,SG�3 <br /> TYPE OF WORK (Check) : NEW WELL. DEEPEN RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION /T7_PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other /77 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing '71, <br /> Domestic/public Driven Gauge of Casing13 <br /> --- - <br /> - / Irrigation Gravel Pack Depth of Grout Seal <br /> Other _/� Rotary Type of Grout - <br /> _L Other ey . y Other Information :a,%, - 6 �cl/1Ei� <br /> PUvT INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PIMP REPLACEIZNT: / / State Work Done <br /> PUMP '2EPAIR: / / State Work Done <br /> DF.gTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I iiereoy agree to co;:zoly 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 /> tCiLL DRILLERS i2 PORT 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. Thr <br /> SIGNED ( �«. ' .. TITLE <br /> (DRAW VtOT PLN ON REVERSE SIDE) t _ <br /> — FOR DE' R.TMENT h; ^'LY <br /> P.iASE i r _ <br /> APPLICATION ACCEPTED B .. . t- DATE <br /> ADDITIONAL CO i NTS. � �� �g/�yT�� Lr r a��.1�,- � la an vAI.,e 4s_, <br /> P i ASE II GROUT r 'SPEC. Gc7s�tJ PHASE I Jt INAL INSP TION <br /> INSPECTION By DATE INSPECTION BY a _ DATEy,lH <br /> CALL FOR A GROUT INSPECTION PFtIiR TO GROUTING AND FINAL INSPECT' . <br />