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k <br /> SAN JOAQUIN LOCAL HE D1MICT� <br /> i f OFF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 _ wmr`T�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT, -1- fho. 2C1_,264V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . 7 <br /> (Complete In Triplicate) <br /> r- 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 /> lCounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,2� _� l�Ir'�r S CENSUS TRACT <br /> Owner's Name Q �n� {—� Z 5 � S Phone <br /> MP3-- 53oQ <br /> Address .v✓rp City <br /> I <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN/7 RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR'/ /PUMP REPLACEMEN /7 <br /> Other J / <br /> 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i' INTI,NDED 'USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled bia.�of Well Casing �. <br /> Domestic/public ( Driven Gauge of CasiAg— <br /> Irrigation Gravel Pack Depth of, Grout Seal <br /> Other l Rotary —Type`of-Grout. <br /> Other Other Information <br /> 1 i <br /> i PU?iP INSTALI:ATIbN: C Intractor I <br /> Type of Pump Ijj 1 R.P. <br /> PUMP REPLACEMENT: /1 / State Work Done <br /> ' PUMP UPAIR: /_/ State Work Done <br /> T Jr <br /> j DFRTRUCTION OF WELL: Well Diameter t4jv ��. ., .�<<< Approximate Depth <br /> escribe (Material and-Procedure I r t ve <br /> I hereby agree to comply with all laws' arid 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 willlfurnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofithe well and notify them before putting the well in use. The above <br /> iinformation is true to the best of my knowledge and belief. <br /> { D TITLE <br /> SIGNED -- <br /> " ` <br /> e (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT� USE ONLY <br /> c PHASE I \ '' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 11 1426 5/731M <br />