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' A_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> CAIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> {��h y, (Complete In Triplicate) <br /> Application is eby 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 Jo: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distr: <br /> JOB ADDRESS/LOCATION 45-1a CENSUS q �gy CENSUS TRACT <br /> Owner's Name �E -/-0 C_ 24�,e_h n Qw 4 / Phone <br /> Address _F e. /-//o x SSa 9-' CityCJ �t�f py_� <br /> Contractor's Na v`a2.� c, '� �, License #/1�3 XrPhone ; <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /_" / PUMP REPAIR �7/ PUMP REPLACEMENT /_7 <br /> Other /_/ <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> f 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/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary '. Type of Grout <br /> Other Other Infoimation <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump ^Q aL- 4 Ov H.P. / <br /> PUMP REPLACEMENT: / / State Work Done I <br /> PUMP REPAIR: State Work Done _� � 4 Ve, <br /> ,DESTRUCTION 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 Distric <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the be of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN VERSE SID <br /> 10 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z yi -72`� <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GR 2NS FTIO PHASEIII/FINAj, INSPECTIOY <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br />