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/; SAN JOAQUIN LOCAL HEALTH DISTRICT Z,O� ~ !30 - t 3 <br />FOf. OFFICE USE. � 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 Issued <br />(Complete In Triplicate) I <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 />.TOB ADDRESS/LOCATION an llAY A L L E& --i Dab PS RD CENSUS TRACT <br />Owner's Name ?o k1V BAR T - Jii/1( - Phone 5(,? - ! <br />Address / 4!9 S 3 e&,41,4CN RL2 City &O'SC,44 O oV 4''A41A- <br />Contractor's Name �a,:,�..,pyyr Liu"� License # zC.5-71/ Phonetl449,2..2 <br />TYPE OF WORK (Check): NEW WELL /—/ DEEPEN"/—/ RECONDITION _/ / DESTRUCTION /-% <br />AL <br />PUMP INSTLATION MP PUREPAIR J / PUMP REPLACEMENT /% ` <br />Other /-7 N1 <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER `}.1 <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 />T Irrigation Gravel Pack Depth of Grout Seal <br />Other. Rotary Type of Grout <br />Other Other Information" <br />PUMP INSTALLATION: <br />PUMP REPLACEMENT: <br />Contractor _ <br />Type of Pump <br />/—/ State Work Done <br />PUMP UPAIR: / J State Work Done <br />,DFgTRUCTION 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 4e <br />(DRAW PrOT PLAN ON REVERSE SIDE) <br />FOR DEPARTMENT USE ONLY <br />PHASE I <br />APPLICATION ACCEPTED BY DATE <br />ADDITIONAL COMMENTS: 1- -3 - 7- 7 <br />PHASE II 9ROUT INSPECTION PHASE III <br />INSPECTIDN BY ZZDATE INSPECTION BY <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />-- E H 1426 _ <br />IAL INSPECTION <br />DATE X-0 <br />5/731M <br />