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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0£. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. 4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued !�� <br /> (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 t.K San Joaquin L ' l Health District. <br /> JOB ADDRESS/LOCATION C� ''�` �rT 1 JET - 1 NIS' NSU TRACT <br /> Owner's Name 'E""� �`/f4Phone2e," e7,�1 g <br /> Address C /0 YzE77 City 046P1 ` <br /> Contractor's Name �! '� r V A-4,PrS License 1#4G 7 373Phone4l 94C341' X_ <br /> TYPE OF WORK (Check) : NEW WELL IX DEEPEN /—/ RECONDITION /_/ DESTRUCTION /? <br /> AL <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT /_ <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER v 1 <br /> 19 INTENDEDWELL CONSTRUCTION SPECIFIC IONS <br /> USE TYPE OF L <br /> Industrial Cable Tool Dia. of Well Excavation } <br /> Domestic/private Drilled Dia. of Well Casing <br />} Domestic/public Driven Gauge of Casing <br /> 1 Irrigation Gravel Pack Depth of Grout Seal $ <br /> Other Rotary Type of Grout" <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: !l State Werk Done <br /> PUMP 'tEPAIR.: / / -State Work_.Done– <br /> pFgTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> 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 best of my knowledge and belief. <br />' SIGNED �� �M�x. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />�. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `r1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Z DATE _7Z6 <br /> CALL FOR A GROUT INSPECTION PRION TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - — 5/731%- <br /> - 1 <br />