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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: f 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1s ki 4 <br /> 3-ado <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5-- 1--7 <br /> (Complete In Triplicate) 7_ SZ- pFl3 <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 Joaquink <br /> Countyy_Ordinance,No,.,-1862 .and.. the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION d -2a;-710 CENSUS TRACT <br /> Owner's NameLj2kn d ustI Phone g - <br /> Address 3 City <br /> Contractor's Name _ t'�1},�I.icense # Phone <br /> TYPE OF WORK (Check) : NEW WELL IV-T DEEPEN / RECONDITION /-7 DESTRUCTION /`7 <br /> PUMP INSTALLATION PUMP PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / — /—� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _10 -- PIT PRIVYfie, <br /> SEWAGE DISPOSAL FIELD `_ CESSPOOL/SEEPAGE PIT y,y� OTHER ` <br /> 1CV <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Tool Dia, of Well ExcavationiP <br /> Domestic/private _ /16 <br /> Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing i10 - ��. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information 3 <br /> PUMP INSTALLATION: Contractor y . <br /> Type of Pump a H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP..-REPAIR: -w = - _/ / St'a'te-Work Done <br />,DESTRUCTION 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 /> 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 J <br /> ....., ... _ _ TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION \\ P I NAL INSPECTION <br /> INSPECTION BY DATE INSPECTId BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7J72 1M <br />