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p CV1U. C41G <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _£.,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �&1- 2,;t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 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 11eal.th District. <br /> JOB ADDRESS/LOCATION G CENSUS TRACT <br /> Owner's Name In 14' _. ...,,.._ Phone �pA620 <br /> 4 <br /> 1 <br /> Address . ---- l 3cc[ . T H=e City <br /> Contractor's Name ` �1A� rr,�] Ikzj , License # Phone 59 C1 <br /> TYPE-OF.WORK-(Check) :,NEW-WELL =/ Y/= DEEPEN '/_/ REWND1-TION-/7/- DESTRUCI'ION�n/ <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other ;/—/ <br /> DISTANCE TO NEAREST: SEPTIC =TA4JK SEWER LINES PIT PRIVY �1 <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing I 0 ; <br /> Domestic/public Driven Gauge of Casi.ngik� t <br /> _ Irrigation Gravel Pack Depth of Grout Seal' _+ <br /> Other ► Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP=INSTALLATION: Contractor,., -»_ AM - <br /> Type "of -Pump I 6j, H.P. <br /> PUMP REPLACEMENT: / / State Work Done �v <br /> -.PUMP'REPAIR: _ z_, . y / / Sta.te .Work�Done =-__. <br /> .DFsTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure '" A r` <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 •'constructfon. 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 o€ ,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. <br /> SIGNED TIT La AR <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED _BY ✓ DATE J �� <br /> ADDITIONAL COMMNTS: V <br /> PHASE Il GROUT INSPECTION PHASE/IIA/FINA4 INSPECTION <br /> INSPECTION BY DATE INSPECTION BYTE - - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> __TE <br /> R <br /> EH1426 5/.731M <br />