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SAN JOAQUIN LOCAL HE TH DISTi t <br /> FOI'. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. zc�^ 7�4,) <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. 1.862 and the Rules and Regulations of the San Joaquin LocalHealthDistrict. <br /> JOB ADDRESS/LOCATION 1 �,, C WS TRACT <br /> Owner's Name A f" i 1r A U ztnI , ----- Phone <br /> Address c City ' <br /> .44 <br /> Contractor's Name �y , n r , --- - License j�/.. Pham <br /> TYPE OF WORK (Check) : NEW WELL 1X1_ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ <br /> AL <br /> PUMP INSTTION / / PL` 1P REPAIR /—/ PUMP REPLACEMENT /? <br /> Other <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 1437 <br /> Domestic/public _ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ta=a <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor �- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> .DFfiTRUCTION 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 /> E FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY by DATE <br /> ADDITIONAL COMMENTS; <br /> P SE i GROUT INSPECTION P S /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL F'OR A OUT INSPECTION PRIOI.t TO GROUTING AND FINAL INSP ON. <br /> r. 5/r /7 <br /> ¢ �t l.nr_ 31M <br />