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•� STAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOF. OFFICE USE: 1601' E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �i�-3 97kJ <br /> THIS PERMIT EXPIRES 1. YEAV FROM DATE 'ISSUED Date Issued <br /> i (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constri ct <br /> E 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 /> e2eZi5- NSUS TRACT <br /> JOB ADDRESS/LOCATION r - t / <br /> Owner's Name _ �j4DAN 1,04 Q U I'� C2 0 1-"ZZY'---- - Phone <br /> I Address .�22 � �/Y city dzg4 "T011/ <br /> Contractor's Name �i�y7��I� �� L LX �� Q• License # 74GA? Phone �G2-16'36`�� <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ I RECONDITION I l DESTRUCTION !? <br /> f PUMP INSTXLATION PUMP REPAIR / /—PUMP REPLACEMENT /7 <br /> Other /_/ A <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial a Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing , <br /> x Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> - Other _ Rotary Type of Grout C <br /> ? Other Other Information ' <br /> a <br /> PUMA;INSTALLATION: Contractor <br /> - - Type of Pump H.P. <br /> PUMP REPLACEMENT: / ! State Work Done <br /> PUMP"-?EPAIR: / _/ State Work Done ; <br /> ` DFT.RUCTION OF WELL: Well Diameter-=- Approximate Depth <br /> - Describe M-ater±al_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._,regulatingrwe11 "construction. Within FIFTEEN DAYS <br /> s <br /> after completion of my work on a new we11, I wuilljnish`'the San Joaquin'Local Health District s <br /> WELL DRILLERS REPORT of the well. and notify them before ptitting the well in use. The above <br /> information is -tr'ue,to•-the-�est`-of:'mi y­knowledge and belief. <br /> SIGNED ----- �__ �_ _ __ - - - -TITLE _ . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLX <br /> PHASE I /l �- <br /> APPLICATION ACCEPTED-BY�j f� ` s ( � tcTC%y< --DATE <br /> ADDITIONAL COVL TENTS: <br /> PHA II GROUT INSPECTION PHASE I IFINAL INSPECTION <br /> INSPECTION BY DATE - , 7 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> S/733.M <br />