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SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> EO:-F, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 u1 <br /> } APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N,. <br /> f <br /> A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /�y <br /> I (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. ZIQ t CENSUS TRACT <br /> Owner's Name Vzr'-s-�_ �S,"r Phone <br /> r <br /> Address3 �Z - _S. _ C' .eo.� f �' �.._ �.o. City <br /> Contractor's Name License #,• cso Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATIOI3 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other J / ``-�� <br /> DISTANCE TO NEAREST: SEPTIC TANK Ze,<) • SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial <br /> Domestic/private fledtool Dia. of Well ion <br /> . Dia. of Well Casing <br /> Cable <br /> r - -- - <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> 1 Other Other Information <br /> a <br /> PUMP INSTALLATION: Contractor �-�- <br /> Type of Pump ji,a2zo's'r. '< _ H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> i <br /> PUMP UPAIR: / / State Work Done <br /> -__ <br /> ,DFsTRUCTION 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 f. <br /> I <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 J <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 - <br /> TITLE _rY.'os.l -�Errrf'rC�"fes. . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATEe//"—lT �7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II , NAL INSPECTION <br /> INSPECTION BY -DATE INSPECTION BYY DATE 7 <br /> CALL FOR A GROUT INSPECTION PRIOR .TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 o 5/.73Im <br />