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WOO <br /> ,!a 11't 1� ZEy� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fOF. OFIICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Ryymade <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued(Complete In Triplicate)Application is here 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 /> i <br /> JOB ADDRESS/LOCATION ZT9 3cl E. 02Ia.,j&,u Arg CENSUS TRACT <br /> Owner's Name RENO &1uNTOL-► Phone Fag-2SS/ <br /> Address _ Z�`b3�J �. 0jRA1,s(,g 8%/M, City , 5SGAt-oh/ <br /> Contractor's Name Anyj< Lieu- eQw%P 6, Aic, License # Z/o z,_l'hone ,�E - a <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other -/_7 <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK t;e SEWER LINES PIT PRIVY <br /> I SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER "^ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /7" <br /> Domest-ic/private Drilled Dia. of Well Casing Z' <br /> Domestic - - <br /> /public Driven �. Gauge of Casing .Z_S0 � ? <br /> Irrigation _ Gravel- ack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> Other .Other Information ' <br /> t <br /> PUMP INSTALLATION: Contractor4LK w, EQu-tP G; <br /> Type of Pump Mal k.,:§M H.P. <br /> PUMP REPLACEMENT: / / State Work Done lei <br /> PUMP UPAIR: / / State Work Done <br /> ,DFATRUCTION 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 ,knoviledge and belief. <br /> �} i <br /> SIGNED - -�r faQW TITLE ALES <br /> ------- — ----- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> ti <br /> PRASE I T NSPECTION PHASE I /FINa INSPECTION <br /> INSPECTION- BY DATE �� - r- INSPECTION BXDAT<41 <br /> E <br /> . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />