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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0T,SOF FICE USE: 1601 E. Razelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z_1 , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a-a3 Z9 <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. 1862andthe Rules and Regulations of the San Joaquin Local H.eal.th District. <br /> JOB ADDRESS/LOCATION /43 `a `)r 5 a CENSUS TRACT <br /> Owner's Name _ /le fit`VY1GtA.) V' /0 _ DC it-�- - -- - -- Phone gJ 7 YS <br /> Address - —=-- -- - - City . . <br /> Contractor's Name o< License # ,fM759 -Phone g,Z�i <br /> � E <br /> TYPE OF WORK (Check) : NEW WELL /X DEEP _/ RECONDITION 'J�/ DESTRUCTION /_7AL <br /> PUMP INSTLATION � PUMP REPAIR / / PUMP REPLACEMENT <br /> Other ./ / <br /> DISTANCE TO NEAREST:, SEPTIC TANK/Q- 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 / U\ <br /> Domestic/private Drilled Dia. of Well. Casing <br /> ' Domestic/public Driven Gauge of Casing E <br /> Irrigation - Gravel Pack 'Depth of Grout Seal __- <br /> Other _ Rotary- Type of. Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor /9�, <br /> Type of Pump _ H.P. L3 0 <br /> PUMP REPLACEMENT / / State Work Done a <br /> ,. I2MP 'tEPAIR: / / State Work Done <br /> ,DFcTRUCTION 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 a otify them before putting the well in use. The above <br /> informati n 's t ue to the best o my owledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -- <br /> OR DEPARTMENT USE ONLY <br /> PhASE I <br /> APPLICATION ACCEPTED .BY . DATE <br /> kDDITIONAL COMMENTS: <br /> :► PHASE II GROUT INSPECTION` P S /FINAJj INSPECTION. <br /> 'INSPECTION BY 4114= DATE INSPECTION B DATE <br /> i CALL FOR A GRO INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. j <br /> . -T IIn/7 �/7'�ZM uJ® ` <br />