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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 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) l <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 Saxe Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. � <br /> JOB ADDRESS/LOCATION 2 3 4 , XAI 6 u l e CENSUS TRACT <br /> Owner's Name S /L G Z4,d Z Phone �- <br /> Address Q a J_M Zy 1, A1 City S 7/CN e-A Gllc <br /> Contractor's Name p� 'amu-r.�-r License ����&Phone y <br /> ----- - - - .., ,L= - <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PLW REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> - - i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation �1 <br /> Domestic/private Drilled Dia. of Well Casing �+ <br /> X_ Domestic/public Driven Gauge of Casing p <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. z <br /> t <br /> PUMP REPLACEMENT: / / State Work Done I <br /> PUMP UPAIR: State Work Done 0a , <br /> ,,DFGTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure f� <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 ly 2 TITLE C�c <br /> "KAW Pr0VPLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMIrENTS: <br /> PRASE II GROUT INSPECTION PHASE I NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY i✓ 7 E <br /> CALL FOR A GROUT-INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 -_ 5/731X <br />