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SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> fOk_ ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �, a tJ <br /> s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ZscF - 2a0-c e <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 --o£ the San Joaquin Local Health District. <br /> JOB`ADDRESS/LOCATI f 'r Q/LC CENSUS TRACT ' <br /> Owner's Name L Phone <br /> Address `L� City <br />� <br /> Contractor's nameENNIN S �BROS. DRILLING CO.'COa INC. License ph n <br /> e522- 643 <br /> 2500 W. RUMBLE RD. MODEST09 CAL. <br /> TYPE OF WORK (Check) : NEW WELL IVI DEEPEN '/_7 RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTLATION REPAIR '/ / PUMP REPLACEMENT / � <br /> AL <br /> Other 1/ / <br /> DISTANCE TO NEAREST: SEPTIC ITANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation _ <br /> Z-�-Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven' Gauge of Casing <br /> Irrigation 1 Gravel, Pack Depth of Grout Seal <br /> Other 1 i— Rotary Type of Grout <br /> 3 Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> JUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> �,DFIZTRUCTTON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Y,herebykagree 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 /> SIGNEDi G 0. INC:-: TITLE <br /> 3 (DRAW PLOT PLAN ON REVERSE SIDE) OMEPER <br /> PHASE i <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY A9- __ DATE -7 <br /> ADDITIONAL COMMENTS: ` <br /> PHA E II GROUT INSPECTION * PHASE III F NAL INSPECTION <br /> INSPECTION BY .: DATE ,INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H '1426 - 5/731M <br />