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�0 SAN JOAQUIN LOCAL HEALTH DISTRICT �� I <br /> tFOc. 017ME USE: 1601 E. Hazelton Ave. , Stockton, Calif. �n y�d <br /> Telephone: (209) 466--6781 1, O <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT. Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED Date Issued (, 3 <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 Health District. <br /> p <br /> JOB ADDRESS/LOCATION p ' '* CENSUS TRACT ! `t5-- 23o--0Y <br /> Owner's Name I-M ,-a Ac i - h-L.. _„---- ^_ Phone <br /> Address �4 - _ City' Cn7d <br /> Contractor's Name a,y, t' License # Phone - G <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/, / PRECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR IKI PUMP REPLACEMENT <br /> Other /_7 --- -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ._ <br /> INTENDED USE TYPE'OF per,WELL CONSTRUCTION SPECIFICATIONS I <br /> Industrial. tCable Tool . .... Dia:' of Well Excavation <br /> Domestic/pr.ivate.: Drilled Dia. of Well .Casing <br /> ' domestic/public Driven Gauge of Casing <br /> Irrigation Gradel Pack .Depth of Grout Seal <br /> Other .. : . . .Rotary Type-.of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �l <br /> Typa of Pump <br /> H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:. /X7/ State Work Done �o✓ae <br /> .DFGTRUCTION OF WELL':' -Well Diameter Approximate Depth <br /> .., Describe Material and Procedure <br /> I hereby"agree' td -' omply 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 near well, I will`-fiitnish 'the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT"of th6'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 TITi:E <br /> ( RA PLAN ON ' VERSE SIDE) , $ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � � 2��� <br /> APPLICATION- ACCEPTED..BY ... DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FlIgAL INSPECTI N <br /> INSPECTION -BY, . .-- -- :....,: : .,< .-DATE ,....:. INSPECTION BY DATE <br /> -,CALL_FOR­A• GROUT=-INSPECTION,,PR CIA-.TO-GROUTING.AND._FINAL INSPECTION— . <br /> E H_1426 _. '^"ti _ . .._. 5,,73 i.M <br />