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lee SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r <br /> Telephone (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Su ya <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1:625 • - ST yfv�6=c (Complete In Triplicate) 2_2 l—i?-v -fj,Z <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 /> JOB ADDRESS/LOCATIONLj 1 YO{ d CENSUS TRACT - <br /> .0 <br /> Owner's Name J A) 1, 40 n ro Phone d �p <br /> t <br /> Address 'Q64 <br /> Contractor's Name License yZ7 Phone <br /> TYPE OF WORK (Check) : -NEW..WRLL 474-y..-DEEPEN= /—.RECONDITION-/.4 --DESTRUCTION / <br /> AL � <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 ��vv <br />' Other <br /> Y <br /> DISTANCE TO ,NEAREST: � SEPTIC,,TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE_ % z TAPE. 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 /> Irrigation Gravel Pack DepthFof Grout Seal <br /> Other <br /> ._ Rotary . Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION., Contractor ,� <br /> Type of Pump H.P. f <br /> PUMP REPLACEMENT: / / State work Done <br /> PUMP REPAIR: / / <br /> State Work Done <br /> DFgTRUCTION OF WELL: -Well Diamefer" <br /> Approximate Depth <br /> Describe Material and Procedure <br /> i 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 anew 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 /> 1 informationi true to the best of my knowledge and belief. <br />'i SIGNED TITLE <br /> f (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPART11ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` L" ATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P1W I;rvtiy NSPECTION <br /> INSPECTION BY DATE INSPEC ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - 5/.731M <br />