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VW+ - , <br /> VVV JOAQUIN LOCAL HEALTH DISTRIC <br /> * <br /> FOR OFFICE USE: 16 Hazelton Ave. , Stockton; Cal <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit tNo. 7J 3 5 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D to Issued -i(-2-8'- 7e, <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 Joaquir <br /> Couptt^y�/pr�nance No. 186 and th ules and Regulations of the San Joaquin Local Health District. <br /> /JAD ��0 - �s-,•• j�w�. Ticc4 /v f�J <br /> JOB DRESS/LOCAT ON ,.gt $ E/N L- G u L/Zrj CENSUS TRACT J 7y <br /> Owner's Name /YJ ONA,0C //6,4fES 7N4L Phone S 376->p6 <br /> Address G/Iclp City <br /> Contractor's Name /�L��L(, �;�� L ��a,,(y, �! License #2 Phone 444 9839 <br /> y In,A*44- Z30 > <br /> TYPE OF WORK (Check) : NEW WELI! / DEEPEN / / RECONDITION /_-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR J / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 175'1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal . Q <br /> Other Rotary Type of Grout %-,4� <br /> Other Other Information r � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done S <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 /> 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 /> SIGNED /if�f�ee.Ilc/� a� TITLE <br /> _ (D PLO PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 3 <br /> APPLICATION ACCEPTED BY (�✓ DATE <br /> ADDITIONAL CO NTS• <br /> S GROUT INSPE ON I / AL INSPECTION p <br /> INSPECTION BY DATEZ�_ INSPEC N B DATE <br /> CALL FOR A ROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />