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u{ <br /> x <br /> n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i-OF. OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '�� r-` 33 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> � <br /> (Complete In Triplicate) 7 <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 11' S CENSUS TRACT 0/_?-0Z0-0/ <br /> Owner's Name L40Vq oePhone <br /> Andress City <br /> Contractor's Name AV264 LPr�1�f„G�iU.✓e�� �Ofl l License # Aj Phonef <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /7 RECONDITION I�T DESTRUCTION r7 <br /> PUMP INSTALLATION /X— PUNP REPAIR }/ / PUMP REPLACEMENT /? <br /> Other ZA i - <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE a T'A'PE OF WELL ..CONSTRUCTION SPECIFICATIONS <br /> Industrial -.�_..._�,_.-,.-_,..-� <br /> Cable Tool Dia. of elf Excavatiah <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-Information <br /> PMIP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done ' r <br /> fi <br /> PUMP 'tEPAIR: /% State Work Done :< <br /> ,DF.gtRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <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 beat of my knowledge and belief: <br /> SIGNED _. TITLE <br /> _ DRAW PLOT PLAN ON REVERSE SIDS <br /> FOR DEPARTkWT USEI ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY "'I DATE �� ? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY� DATE 7—.2 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND F'INAL1.INSPECTION. <br /> E H 1426 <br /> . _. 5l731rt <br />