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i _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> or. -OFFI.CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,? :-_6-�>L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /p -)Z-2,( <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 Health District. <br /> JOB ADDRESS/LOCATION X ;�ar � /i't�- ¢ !T' f� S' CENSUS TRACT <br /> Owner's Name A9zf�,2! Z .e .S 3 7'o.g. Phone <br /> Address :1%'�� _..� G/ sem?' t� } City ► ,ala 7z <br /> Contractor's Name ��'''- ,�_p"r �� r4-1te= - AJC', License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN/-7 RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION /Z-PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other / / <br /> eOStr!2. 0 -'S Gt/ < <br /> DISTANCE TO NEAREST: SEPTIC TldiK SEIZER LINES PIT PRIVY <br /> P?!?SWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 __4,,=-,Gravel Pack Depth of Grout Seal <br /> Other Mary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor -dam 11'1:2. ;2, !a Z/ ?)?? ' c _ 7-"e , e, <br /> Type of Pump -r-a. -Z r 71 C — H.P. / e,0 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DF�TRUCTION 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 ' f' r <br /> (DRAW PLOT PLAN ON REVERSE SIDE cJ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II NgtC&ION PHASIZWjNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />