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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOi'. 6171710E USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> �. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -17,-) l.-) <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /� CENSUS TRACT el <br /> 4 <br /> CENSUS <br /> Name4j�,V. , t Phone <br /> Address City <br /> Contractor's Name License # /'/ a-v-_Phone J;4a-S-9 t1� <br /> 2500 W. RUMBLE ROAD <br /> TYPE OF 'WORK (ChecNWDE*16a 4L / CE 1?W _/ RECONDITION f_1 DESTRUCTION _� <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 — <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 OQ <br /> riDomestic/privata l�Drilled Dia. of Well Casing <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 <br /> Type of Pump H.P. <br /> PUMP REPLACE11ENT: / / State Work Done <br /> PUMP 'ZEPAIR: / / State Work Done <br /> ,DF",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 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 /> I1ELL 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/'J� TITLEX_4ez1.< <br /> (DRAW -PLOT PLAN ON REVERSE SI <br /> PHASE I �- <br /> R DE TMENT USE ONLY <br /> APPLICATION ACCEP ATE <br /> ADDITIONA.L COi S. <br /> 5E ROUT INSPECTION P I/ AL INSPE7/711 <br /> INSPECTSO DATE 7�-7 INSPEC ON DATEi1CALL IOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 14265m 1 .� <br /> H 14 -- <br />