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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 SCANNED 7 37S{� <br /> APPLICATION FOR WELI, CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> Applicatio is hereby made to the San Joaquin(Complete Triplicate)In <br /> Local 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 ,�u le nd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' <br /> �+ G CENSUS TRACT <br /> Owner's Name / 2 Phone 3 Cc 1 <br /> Address y ti City <br /> Contractor's Name XA-a-:--C2 !- L, License Phone —,n3 <br /> —,n3� <br /> ! d <br /> !t—L <br /> TYPE OF WORK (Check): NEW WELL /�-f�DEgpEN /_� RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSfiALLATION ( UMp REPAIR / / PUMP REPLACEMENT /-7 <br /> Either / / <br /> DISTANCE TO NEAREST: SEPTIC TANK . ,t_SEWER LIMES IT PRIVY - , <br /> SEWAGE DISPOSAL FIELD 5`�-/ SPOOL/SEEPAGE PIT/:OTHER --� <br /> 4 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT ONS � <br /> Industrial Cable Tool Dia, of Well Excavation <br /> z---1Jo—me s tic/private Drilled Dia, of Well Casing '-2 % <br /> Domestic/public Driven Gauge of Casing 2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other 4---Rotary Type of Grout �9 <br /> Other Other Information CO., <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump y� � . H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 /> info tion is true to th .est y knowledge and belief. <br /> SIGNED <br /> TITLE <br /> PLOTPLAN ON REVERSE SIDE <br /> FO ARTMENT USE ONLY <br /> PHAAft� _ <br /> APPLICATION ACCEPTED B �. � DATE i Z/7 C <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION/ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 � /72 1M <br />