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G� ;SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Df.:01-�' C uSE• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> " APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No � �_S � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br />' (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instar, 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 Helth ist ict. <br /> ' ? i�Q� <br /> 30B ADDRESS/LOCATION z� youth of Brandt Rd.s` f C <br /> � Mi. West olements CENSUS TRACT <br /> XPP <br /> t Owner's Name in B a Phone 2- L <br /> Address 69A8 Arrowwood Drive, Mode to C <br /> City . . <br /> 4 <br /> Contractor's Name v' D ' 7 License # 240107 Phone 931- 6$ _ <br /> 'TYPE OF WORK (Check): v NEW WELL "/x DEEPEN �/ / RECONDITION_/_/ DESTRUCTION I�T <br /> PUMP INSTALLATION /,x/ PUW REPAIR'/ / PUMP REPLACEMENT / <br /> Other / <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TAi�3K Mi, SEWER LINES Mi, PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD . CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ` - Cable Tool Dia. of Well Excavation -- Ila" _ <br /> I Industrial v <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 6 <br /> a Irrigation Gravel Pack Depth of Grout Seal e <br /> Other <br /> Rotary Type of Grout n <br /> Other Other Information <br /> r <br /> PL`MP INSTALLATION: -.:Contractor Purviance D i't ers H.P. . 75 <br /> -Type of Pump Turbine - <br /> PUMP REPLACEMENT: `. / / State Work Done <br /> PUMp�'IPAIR:_ /-"State Wv�rk�Done <br /> Approximate Depth <br /> ,pFgTRUCTION OF WELL: Well Diameter <br /> r Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> egulating well construction. Within FIFTEEN DAYS <br /> and the State of California pertaining to or r <br /> ill furnish the San Joaquin Local Health District <br /> after completion of my work on a new well, I w <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 /> I TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I DArElDf(7 <br /> APPLICATION ACCEPTED .BY r -- <br /> ` ,,�,ADDITIONAL COMMENTS: PHASE IIT/FINAL INSPECTI N <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE• <br /> INSPECTION BY DATE <br /> CALL-FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. /7 <br /> f ![// <br />