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SAN JoAgUIN LOCAL HEALTH DISTRICT t <br /> 'Ot. 01.FICL USE: 1601 E. Hazelton .Ave. , Stockton, Calif. I <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ss;S�2DccJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby Wade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. , This application is trade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San oaquin Loc ktealth District. <br /> JOB ADDRESS/LOCATION &/ ,ALL f Q I�cp, CENSUS RA <br /> Owner's NamePhone,:,5Ur— 41A�,e <br /> Address I �� /V /d 1� R-� _ City <br /> Contractor's Name License # # .Z Phon . -' <br /> 1 _ r <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /—,/ DESTRUCTION /? <br /> PUMP INSTALLATION [X— PUMP REPAIR -/ / PUMP REPLACEMENT J� <br /> Other / / s. <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK 70 SEWER LINES PIT PRIVY + <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAG2'PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, r Cable Tool Dia. of Well. 9 <br /> DExcavation A <br />. omestic/prlvate . .� _. ._._ Drilled � � _ Dia. of We11 .',Casin <br /> Driven Gauge of Casing ,f <br /> +rrtption Gravel Pack, Depth of Grout Seal jr SK <br /> Other Rotary-�L Type of Grout' '/ <br /> + Other Other Information <br /> fX ` <br /> PUMP INSTALLATION: Cont <br /> ractrr /I <br /> ¢ 0,Qf" <br /> Type of Pump �� 4 " ° H:P. <br /> 1rw <br /> P UMP_ REPLACEMENT:t. / / State Work Done <br /> PUMP UPAIR: State Work Done <br /> f- I <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> I 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 neva well, I will Burnish the San Joaquin Local Health District a ,, <br /> WELL DRILLERS REPORT of Ehe well. and notify'fhein'before putting--the well' Yri use.T#,—Above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY if DATE <br /> O);/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GJWUT INS ECTI N PHASE III/FINAL INSPEC'TI N <br /> INSPECTION BY DATE 2¢, INSPECTION BY �_./i DATE Q <br /> °• CALL FOR-�A- GROUT N PECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> , r <br />