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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I0�'. Ol'1TCE USE: 1b01 E. Hazelton Ave. Stockton, Ca f <br /> - 13. . <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) Os-/.... Zp© -{g <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 Ord1inya�nce- N/o..[i 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADD! S/LOCATION k CENSUS TRACT J'l 7 <br /> Owner's Name Phone-3G<Y- Y/X_�, <br /> Address City <br /> Contractor's Name � � License �� Z-p hone-79,5-/3 Y7 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ / RECONDITION I_/ DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a le Tool Dia. of Well Excavation <br /> A-1"V—omesti.c/private Drilled Dia. of Well Casing j <br /> Domestic/public Driven Gauge of Casing ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor(--nj. F .° <br /> Type of Pump / �1._...� � -- H.P. <br /> _.. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Do/me — - <br /> f DFRTRUCTION 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 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 �— �- _ TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDT17 - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY M DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II ,/FINAL INSPECTION <br /> INSPECTION BY DATE -Z#17V INSPECTION BY DATE I '7ly - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ks'' <br /> E H 1426 5/731M <br />