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/&SA?JOAQUIN LOCAL HEALTH DISTRICT <br /> IOI. OFFICE USE: <br /> - 1601 E. Hazelton Ave. , Stockton, Calif. <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 Issuedj--/.-2,5 <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 _ b4 SS e . I !L D 43 o; -N 5 6e a fLel? _ CENSUS TRACT <br /> Owner's Name PASSO OROS Phone ay- /7, ` <br /> Address ?►- Lcity 7-1(Al- <br /> Contractor's Name License # & S`7G Phone G <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION -/-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TA14K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE T'A'PE 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 tz <br /> Other Rotary Type of Grout <br /> _ Other Other Information " rJ, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S 4dr � H.P. X <br /> l PUMP REPLACEMENT: State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> eeq,_DRsTRUCTION OF WELL: Well Diameter Approximate Depth <br /> E Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I 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 /> 3 <br />� SIGNED <br /> (D LOT 0 REVERSE SID <br /> OR DEPARTMENT USE ONLY <br /> i PHASE I D <br /> APPLICATION ACCEPTED BY �G7 ,c1 DATEJ� <br /> ADDITIONAL CO:2E�NTS: <br />�. PHASE 11 GROUT INSPECTION PHASEXX/tINAJ41INSPECTION <br /> INSPECTION BY DATE INSPECTION BYATE y ., <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL• INSPECTION. <br /> E H 1426 5/731M <br />