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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> JFOR OFFICE USE: 1601. E. Hazelton Ave. , 'Stockton, Calif. <br /> W Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -/O Z z' <br /> THI5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued lZ jai <br /> (Complete In Triplicate) <br /> Application ��ereby made to' the San Joaquin Local Health District for a permit to construct <br /> and/or Inst 11 the work herein described. This application is made in compliance with San Joaquin <br /> County' Ordinatnce •No. .1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRE55/LOCATION j. ae�ZZ,- Rd. ,�. CENSUS TRACT <br /> -� <br /> Owner's Name S �.l � Phone <br /> Address Ss�I?� _ City ESC AC7,z1 <br /> Contractor's Name <br /> ...,.�� �, 4,1� � License jj Phone <br /> TYPE OF'WORK (Check) : NAL <br /> EW WELT, / / DEEPEN / 7- RECONDITION %� ' DESTRUCTION" /7 - <br /> PUMP INSTLATION, / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / f — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool 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 IN Seal <br /> Other Rotary` Type of �Grout <br /> Other Other Information <br /> PUMP INSTALLATION: 'Contractor %�_ S4 , �.�c7 �Ii y Vo <br /> ' Type of Pump �— H.P. <br /> PUMP REPLACEMENT: / / State Work Donee <br /> t <br /> PUMP REPA-1-R-o .�--^� .�. -/�/< -5-ta•te Work' Dane <br /> ESTRUCTION 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 new well, I will furnish the San Joaquin Local Health District a <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. 1 <br /> SIGNED - . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 7-1777777 7/7 <br /> PHASE II G OU NSPECT' ON P II/F INSPECTION <br /> INSPECTION BY = - DATE - - 2--- INSPECI'I0 BYTE -. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION'. <br /> - _ _�; . <br /> -_ STT/7Z""'1M� --, e 1 <br /> - <br />