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LIX/61 - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O _,OLFICE <br /> USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 20 4J ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) Z!3 -170- q/ <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 /> Sia 2 5" t G=��i T" <br /> JOB ADDRESS/LOCATION400/ CENSUS TRACT - <br /> Owner's Name / r e, Phone <br /> Address Q . Cityf'I SIS 3a <br /> Contractor's Name 5 OS ®. License # ?C/4 Z3Phone ' <br /> TYPE OF WORK (Check): NEW WELL /Ifil DEEPEN / I RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other ,/ I <br /> VI <br /> DISTANCE TO NEAREST: --SEPTIC TANK �_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> C' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> RDome stic/.private, _ ^ �Drilled�... TM. �. Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Other V_ Rotary Type of Grout -- <br /> Other Other Information Lsfah -All +C' <br /> PUMP INSTALLATION: Contractor <br /> Type-of Pump H.P. . <br /> PUMP REPLACEMENT: f / r State Work Done <br /> PUMP 'tEPAIR: / j State Work Done <br /> DFRTRUCTION 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 /> z 14ELL 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 /> SIGNEDTITLE <br /> t <br /> ( <br /> PLOT PLAN ON REVERSE SIDE) <br /> E FOR DEPARTMENT USE ONLY <br /> t PHASE I <br /> APPLICATION ACCEPTED .BY DATE. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL I TION. <br /> E H 1426 5/731M <br />