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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � :,, • <br /> F0r..,OF FICE U E• 1.601 E. Hazelton Ave. , Stockton `Calif: : <br /> Telephone: (209) 4664781,x.: <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> -2 <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 Regulations of the San Joaquin Local: lleal.th District. f <br /> JOB ADDRESS/LOCATION �1 <br /> O ► �' G�i4 bo Ct CENSUS TRACT <br /> Owner's Name e(AU2 0/ /�!R .�/fie�,t�P', .,t 1 .._ 1_.Qi a.1 Phone <br /> Address ,�- /.,c! Cityd�d, <br /> Contractor's Name License #/ Z4LLPhone --747e. <br /> TYPE OF WORK (Check): NEW WELL I I DEEPEN '/ I RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / v/ PUMP REPAIR '/ / PUMP REPLACEMENT �- <br /> Other I / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Toole Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Caging <br /> _ Domestic/public Driven Gauge of Casing �? <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout - <br /> Other e''r Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /KJ State work DomeA 6 <br /> PUMP UPAIR: / / State Work Done <br /> DF-,TRUCTION OF WELL: Well Diameter r. Approximate Depth <br /> Describe Material and Procedure <br /> h i <br /> r' I hereby agree to comply with all laws and -regulations of the San Joaquin Local Health District <br /> I and the State of California pertaining to or regulating, well construction. Within F'IF'TEEN DAYS <br /> after completion of my work on a new well,a I will ,furnish the San Joaquin Local Health District a.' <br /> 3 WELL DRILLERS REPORT of .the well .and 'notify' them before putting the. well in use. The above ! <br /> information is true to the bestofmy knowle belief. <br /> i SIGNED 1a2P'�� tr. ITLE r i <br /> i ( W PLOT PLAN ON RE SE SIRE) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE r 7 <br /> ADDITIONAL COMMENTS: <br /> s <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPEGTIQN <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR -A GROUT INSPECTION PRIOR TO GROUTING AND FINAL,INSPECT N. r <br /> E_H 1426 <br /> 5,2731. ° <br />