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SAN JOA UIN LOCAL HEALTH DISTRICT SCA NNE , Alsip r <br /> 70—F."OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y-_7,Z3d <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 Dis ict for a permit to construct <br /> and/or install the work herein described. - This application wade in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of he San Joaquin Vocal Health District. <br /> JOB ADDRESS/LOCATION 2 1 7 21 _-_ _ CENSUS TRACT <br /> Owner's Name c /`1 V t.�iGG Phone <br /> Address °�l C' City <br /> Contractor's Name License Fhon,. �+ <br /> TYPE OF WORK (Check) : NEW WELL, 1✓ r DEEPEN /_/ RECONDITION [—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION X/ PUMP REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> T Domesticlprivate <br /> =Drilled Dia. of Well Casing <br /> '" Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor VA­r <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP 'REPAIR: /% 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 /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The abov <br /> information is true to the best of my knowledge and belief. <br /> SIGNED e R _ -- -- TITLE <br /> (DRAW PLAT PLAN ON REVERSE SID <br /> OR DEPARTMENT USE ONLY <br />` PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL C041MENTS: <br /> PHA OUT NSPEC'IIO FHAS III/ NAL INSPECTi <br /> INSPECTION B `.�' TE 1 INSPECTION BY ,� -)DATE <br /> CALL £' A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS CT ON. <br /> E H 1426 -__- 5/731M <br />