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O SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 113- So 5 <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 Health District. <br /> JOB ADDRESS/LOCATION A/ R/ 9 G v a li2lc CENSUS TRACT <br /> Owner's Name L Z A 40 A, A/- Phone 3$ 'C,� Z3 <br /> Address 12 nc ,,; Sw Z?a c XLtsr&%x // City <br /> Contractor's Name /, D� �, .y am License #,2290/0 Phone - 3et;;�?d__7 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /77 RECONDITION /—T DESTRUCTION /_7 <br /> PUMP INSTLATION /PUMP REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> Other / / <br /> p _ <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 <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 Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> ( fo & <br /> PUMP INS ALS _LATION: Contractor x�Xe t) <br /> `— — Type of Pump H.P. <br /> PUMP REPLAC ENT: I / State Work Done <br /> PUMP REPAIR:, / / State Work Done <br /> JDESTRUCTIO 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 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ;7Z�27 <br /> APPLICATION ACCEPTED BY TE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PWf <br /> INSPECTI <br /> INSPECTION BY DATE INSPE ATE • <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 T/72 1M <br />