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SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> POF.;OFFICE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> o Telephone: (209) 466-6781 <br /> 5 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per <br /> No. L� <br /> Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM 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 insLall' 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 IleaT�lth District. <br />. JOB ADDRESS/LOCATION' '�s.� � �®c�4' �NSUS TRACT <br /> - <br /> Phone <br /> Owner's Name 1 <br /> Address <br /> M l city ' 9 TAW <br /> License #.2 gZ7 Phone YAG�/ <br /> �. Contractor's Name <br /> STRUCTION /-7 1-7 <br /> TYPE, OF WORK (Check) : NEW WELL I I DEEPEN / /UMP REPAIR/NI/ PUMPEREPLACEMENT — <br /> PUMP INSTALLATION P <br /> Other ./ <br /> d. <br /> DISTAINCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL U <br /> Industrial Cable Toole 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 b� <br /> Other. Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor H.P. ./�^- <br /> Type of Pump <br /> PUMP REPLACEMENT: / f State Work Done <br /> ! PUMP UPAIR: / State Work Done <br /> E ,DFsTRUC_TION OF WELL: Well Diameter <br /> Approximate Depth <br /> ` Describe Material and Procedure <br /> i ulations of the San Joaquin Local Health Distr <br /> I hereby agree to comply with all laws and reg <br /> ict <br /> and the State of California pertaining to or regulating we11 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will _furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above u <br /> information is true to the best of my knowledge and. belief. <br /> TITLE p.hw �-- <br /> { SIGNED 2E <br /> RAW PL LAN ON REVERSE SIDE) <br /> ' tA FOR DEPARTMENT USE ONLY <br /> PHASE I OF DATE gz-201- <br /> APPLICATION <br /> ACCEPTED BY <br /> ADDITIONAL COMMENTS: P E I /FIVNAL INSPECTION, <br /> r PHASE II GROUT INSPECTION DATE / 76 <br /> INSPECTION BY DATE INSPECTION BY <br /> t� CALL�F'3R;A•GROUT YINSPECTION--PRIOR-�-TO'--GROUTING AND--F-INAL"INSPECTION. r � - ,/7 <br />