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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> --r-OT.-OFFICE USE;. i6Ol E. Hazelton Ave. , Stockton, Calif. ; <br /> Telephone: (209) 466-6781 c'r <br /> r APDL CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE.'ISSUED Date Issued <br /> (Complete In Triplicate) ! Cf3 Z7© Z 3 <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 ard Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION •. :� teC)(j +rp, .FAL CENSUS TRACT <br /> Owner's Name ✓ "l/9 Phone la <br /> Address C3 $� All. lcity <br /> �G/2 6U clc�r ai<< <br /> •- <br /> Contractor's Name L 6 /1( {z License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION 1 / DESTRUCTION /_7 <br /> PUMP IN5 ALLATION PUMP REPAIR / / PUM�EP CEMENT 1_7Other ? �q <br /> DISTANCE TO. NEAREST: SEPTIC TANKSEWER-LINES W PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD,; P CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE :TYPE OF WELL 11, CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Toad; Dia. of Well Excavation <br /> Domestic/private i Drilled,;"" Dial of Well Casing <br /> D stic/public i Driven Gauge of Casing <br /> Irrigation I Gravel P9ck Depth of Grout Seal <br /> Other t Rotary C; Type lof Grout ro <br /> t Other C_) Other- Information <br /> PUMP INSTALLATION: Contractor <br /> Type 6f Pump H.P. <br /> PUMP REPLACEMENT: / / (State Work Done w <br /> PUMP 'tEPAIR; /% state-Work-Done � N S_T�� L 1/` l�.c� P ,(� S ! r- Y(ffA yVe: /L <br /> ,DF'1,TRUCTION 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 ertainin to or regulating well "construction. <br /> $ E B within FIFTEEN DAYS <br /> after comple ' of my work. i�n a new well,NI wi l fu iigii�the San Joaquin Local Health District a <br /> WELL DRILL RS RE ORT of .the well and notify them before �uttilg the well in use. The above <br /> informatio is t ue to the best of my knowledge and belief. ! <br /> SIGNED4p, & TITLE <br /> (DFAR PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE } <br /> ADDITIONAL COMMENTS: - 4 <br /> PHASE II PSROU)j IN&EGTWIV PHAS INSPECTION <br /> INSPECTION BY ATE INSPECTIONBY / DATE <br /> - CALL FOR A GROUT INSPECTION PRIOR TO-GROUTING AND FINAL IN ON,41 � <br /> E H 1426_ _ I Ef /7•z <br />