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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'OF.' OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct ' <br /> anal/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 /> JOB ADDRESS/LOCATION r 160,61.E. _Eight Mile Road CENSUS TRACT , <br /> Owner's Name STEVE SOLARI Phone <br /> Address - --15988-E. Ei ht Mile Road City ' ' Lind•en <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW .WELL / / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION PL-W REPAIR/ / PUMP REPLACEMENT <br /> Other 1_7 — <br /> DISTANCE TO NEAREST;'- SEPTIC.-TANK SEWER LINES PIT PRIVY n <br /> Unknown SEWAGE,. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � <br /> Replaced old pump <br /> INTENDED USE TYPE OFI WELL CONSTRUCTION SPECIFICATIONS � <br /> IndustrialCable'Tcial Dia. of Well Excavation <br /> XX.. <br /> x _ Domestic/private ns ## . Drilled,` Dia. of Well Casing <br /> Domestic/public - Driven Gauge of Casing -_ <br /> Irrigation Gravel Pack Depth:�of •Grout_Seal ^--- <br /> Other `Rotary Type rout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump SYreersi hle _-- H.P. <br /> PUMP REPLACEMENT: fes/ State Work Done .}.enlace old limn <br /> 4L:; <br />! --PUMP-'tEPAIR: /: J State Work Done <br /> t <br />' L 'WDelscrDibemMatetTeFr— <br /> iland - -- � Aproximate-Dept <br /> ,AFqTRUCTION-OF`WEa <br /> Procedure <br /> I hereby agree to comply with all laws and regulations of the San, Joaquin Local Health District <br /> and the .State of C .ifornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after co ►pletion of my work on a new well,, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS RER&T of .the well and notify them before putting the well in use. The above <br /> information 's- ,true to the best of my knowledge and belief. i <br /> SIGNED TITLE �•(/?/ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -- <br />�. OR DEPARTMENT USE ONLY <br /> a PHASE I <br /> APPLICATION ACCEPTED .B c.f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P 1,LL.INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 711 . <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS 1 <br /> E H 1426 .5/731x1-- 1I . - <br />