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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O OFFICE USE: 1601. E. Hazelton Ave., Stockton, Calif. <br /> - Telephone: (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � _ t,b-? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _L2-3-13 <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. 186r2 and the Rules and Regulations of the San Joaquin Local Health Dis4rict. <br /> JOB ADDRESS/LOCATION 'i COS 2- CENSUS TRACT - � <br /> F Owner's Name p 5R Phone <br /> Address ,g I � City aA�1J <br /> u <br /> Contractor's Dame , d�t1 License �� p/ Phone �c '2?o7 <br /> TYPE OF WORK (Check) : kNEW WELL ./ J DEEPEN / / RECONDITION /—�J DESTRUCTION' /? <br /> AL /—/—PUMP <br /> - -'— -_ <br /> PUMP INSTLATION PUMP tEPAIR / / PUMP REPLACEMENT /7. <br /> Other / / — <br /> II "- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G� <br /> Industrial ":j Cable Tool Iiia. of Well Excarration <br /> Domestic/private. Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other , Rotary Type of Grout s <br /> Other Other Information <br /> P ; <br /> UMP INSTALLATION:CATION: .. . <br /> . Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done } J,(r/ SG� <br /> i PUMP `tEPAIR: w - ,; / ./ State Work Done <br /> DF-ZTRUCTION OF WELL: w 'Well D ameter 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 Califoxniafpertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my.iwork on a newdrell, twill. furnish the San,Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well andVnotify �them before putting the well in use. The above <br /> i <br /> information. is true to.ithe best of my knowledge and belief. <br /> SIGNED TITLE r <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I <br /> APPLICATION ACCEPTED .BY C�. DATE <br /> ADDITIONAL COMMENTS: <br /> PHA GROUT INSPECTION P -IAM5LL INSPECT <br /> INSPECTION BY DATE INSPECTI N BY DATE , - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - 5/731M <br />