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r..,....► <br /> - --- <br /> 1. <br /> - - ii <br /> SAN JOAQUIN LOCAL NEALTH DISTRICT _{ <br /> F OFFICE USE: 1.601 E. Hazelton Ave. , Stockton , Calif. <br /> Teaephone: (209) 466--6781 <br /> " APPLICATION FOR WELL •CO1gSTiUCTION OR PUMP PERMIT Permit No. Z2 - z S <br /> THIS PERMIT'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued IL- -�y � <br /> (Complete In Triplicate) i <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 /> JOB ADDRESS/LOCATION 0Z? ✓c!Z , CENSUS TRACT j - 13 <br /> Owner's Name, 4 f&e� z9e—e&A - Phone 'J L3-,VV4 <br /> Address 3 v City <br /> Contractor's Name License # //G 3 2-2-Phone �Z <br /> TYPE OF WORK (Check) : NEW WELL, D.EEREN, /_/z RECONDITION /-/—DESTRUCTION- <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 3? : / SEWER LINESPIT PRIVY ! <br /> SEWAGE DISPOSAL oFIELD `fl` _ CESSPOOL/SEEPAGE PIT 1 OTHERII <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. -of-Well Casing o <br /> Domestic/public Driven Gauge of Casing = '' <br /> Irrigation Gravel Pack Depth of Grout Seal I �4 <br /> Other T Rotary Type of Grout <br /> Other , Other Information ' <br /> PUMP INSTALLATION: Contractor led- 1 0 o <br /> Type of Pump NORTH MAIN STREETH.P. <br /> _ r E MANTECA, CALIF. G'Q . , <br /> , 7 � _ k , <br /> PUMP- REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /-7 State Work Done <br /> �_ _ F roxima,te'De th <br /> ,DESTRUCTION OP-WELL•:- Well Diameter '" -x' APP �. P. <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 riotify-them before putting; the well in use. The above <br /> information is true to the best of my .knowledge and belief. <br /> SIGNEDJ66TITLE <br /> (DRAW P 0 PLAN ON REVERSE SIDE) <br /> —9,__�57 <br /> DEPARTMET USE ONLYPHASE I APPLICATION ACCEPTED'�BY �r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -5D-,P,) <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4172 1M G <br /> l � <br />