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SAN JOAQUIN LOCAL HEALTH DISTRICT �) <br /> OF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ll" <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) <br /> Applicatioh As ere y 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 ?37: C- X cll rj d ara ^ CENSUS TRACT <br /> Owner's Name 62ffor 4-e Y/m -rev nle,- T r Phone 36$- <br /> / nn � <br /> Address S 7 6 e6 Kd City /__Q i-,y,0 <br /> Contractor's Name A M• 61-'r sS Lu ea a,, (>i„a License #af,?3�0 Phoner <br /> TYPE OF WORK (Check) : NEW WELL ti� DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 �$.) <br /> PUMP INSTALLATION /(1/rUW REPAIR / / PUMP REPLACEMENT /- u <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _t,,-- rrrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout f <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor --AD c WP z /�»��(� TV C <br /> Type of Pump tl• / � H.P. 7s�L <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PdASE I <br /> APPLICATION ACCEPTED BY DATE Z,2--T` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION tl PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE i <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO <br /> E H 1426 - 5/731M <br />