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SAN JOAQUIN LOCAI. HEALTH DISTRICT <br /> FOE OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,� —�oel : <br /> } <br /> THIS PERMIT EXPIRES l 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 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 /> r <br /> _- CENSUS TRACT - <br /> JOB ADDRESS/LOCATION /5552 CCs acl< � ' <br /> ` <br /> Owner's NameVit•►,+�.1. Co 1_( weak -- - _—_ Phone <br /> l <br /> Address kL. IaCity S i C)C-Arot-) <br /> _ r <br /> Contractor's Name -4/IV 0F TM f 1'1 License 0 V5Y3 Phone69�- 1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN"; /CONDITION DESTRUCTION <br /> PUMP "INSTALLATION / PUMP�ItEPAIR-/ / PUMP REPLACEMENT <br /> Other; / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE `OF'WELL,�' CONSTRUCTION SPECIFICATIONS <br /> Industrial r _ `•. Cable/Tool Dia. of Well Excavation <br /> f Domest'ic'/ptivate� Drilled Dia. of Well Casing <br /> Domestic/public �.� , � Driven Gauge of Casing <br /> Irr.igation ---t -`` -- Grayel. Pack Depth of Grout Seal ' <br /> Other '"•ti Rotary_. Type of Grout <br /> „r <br /> Other Other Information �? <br /> PUMP INSTALLATION: Contractor _ <br /> 1 `Type. of Pump �s SLAAMeas)6-1 - —• H.P. <br /> PUMP REPLACEMENT: / /'" 'State-Work"Done—'- -.—' <br /> PUMP. 2EPAIR: /y / ;State .Work: Done <br /> _ <br /> ,DRgTRUCTION OF WELL: Well 'rDiameter Approximate Depth: <br /> Describe Material and Procedure <br /> S 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 /> 14ELL DRILLERS REPORT of .the 'well and notifjr them before putting the well in use. The above <br /> information is true to the best of my knowledge and. belief. <br /> SIGNED �'G � / TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DAT <br /> ADDITIONAL COIN�IENTS: <br /> PHASE Il GROUT INSPECTION PHAS INSPECTION <br /> INSPECTION BY DATE INSPECTIflN .BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPP71J <br /> E H 1426 5/7.31M � <br />