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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF *OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. f� <br /> Telephone: (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued //-3/-7y <br /> (Complete In Triplicate) <br /> Applicatio s ere y 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 Health District. <br /> JOB ADDRESS/LOCATION 737 C' ,4Cg,,ry2o l:l CENSUS TRACT ' <br /> C.J <br /> Owner's Name t57f-01-�,e <br /> S11-1 j0—re-y clFi' r/P r Phone .76 Cr- lv7,(2 <br /> T 6` <br /> Address 2226 i ca ta 6 r-,a City ACQ <br /> Contractor's Name rgss u ele t)y,, License #,2&JO Phone��� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION f <br /> AL <br /> PUMP INSTLATION / `MP REPAIR / / PUMP REPLACEMENT /7 V <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> __L,CTrrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor .I %y <br /> Type of Pump -- •-st e.�� H.P. 7e,> <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br />,DFRTRUCTION 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. <br /> SIGNED � , TITLE <br /> (DRAW.PLOT PLAN. ON REVERSE SIDE) a <br /> FOR DEPARTMENT USE ONLY <br /> P#iASE i /'�� / <br /> APPLICATION ACCEPTED BY L/ <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> �� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO �"Occ'c <br /> E H 1426 - 5/731M <br />