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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,?73,oP <br /> THIS PERMITEXPIRES <br /> 1 E R FROMDATEISSUED Date 'Issued <br /> (Complete <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 �O 3 C13 ,� �A D ,,V CENSUS TRACT' s <br /> Owner's NameJ!O V1 CRY_.---- -- -- - Phane <br /> W• s. ,�. <br /> Address S City z55C 4/0y <br /> Contractor's Name' - 7-0, .5�7- So Al License # 279aA9 Phone ggg 2D <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN RECONDITION /_ DESTRUCTION <br /> PUMP INSTALLATION /V/'_PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other .r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t <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 1 Gil <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION* Contractor 7D. S At 4 Sp 4,� <br /> Type of Pump 5 �� : . H.P. <br /> PUMP REPLACEMENT: / / State Work :Done ili l <br /> I�PUMP REPAIR.- - / / State Work Done <br /> J)ESTRUCTION 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 puttini -the cell in use. 'l The above <br /> information is true .to the. best of my knowledge and belief. i <br /> 99 <br /> SIGNED -- - _ _ _ TITLE <br /> T. <br /> f/ (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY a DATE <br />- ADDITIONAL COMMENTS: i <br /> r. PHASE II GROUV INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY L t DATE //- 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, I -- <br /> E H 1426 7172 1M <br />