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Ye N ON L v <br /> - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:OFFICE USE: 1:601 t4 Hazelton Ave.. , Stockton, Calif. <br /> ;Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;�Y- 3T f 4,) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7 3I- <br /> ;i (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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J I Z CENSUS TRACT <br /> Owner's Name 2' e� 1--Az Phone 2 22 S- <br /> -Address �%�/Lt_ - -=- : . -- City <br /> Contractor's Name /" !/4GIn 441D - -- License # Phone i <br /> TYPE OF WORK (Check) : NEW WELL/ / EEPEN '/ RECONDITION f-1 DESTRUCTION /-7r <br /> PUMP INSTA LATIO _ TMP REPAIR / / PUMP REPLACEMENT /- f <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <br /> Domestic/private Drilled Dia. of Well Casing ` <br /> Domestic/pul c Driven Gauge of Casing <br /> Irrigati nGrave.l� k -Depth of Grout Seal <br /> Other Ro�taa <br /> Other Information J <br /> 64, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. ° <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP 'tEPAIR: /�/ State Work Done <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sao. 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 "s true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY X/� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _ _. . .__ 5/731M <br />