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Zoe- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L"Of.�03'I"ICE USE: !!!�// 1601 E. Hazelton Ave. , Stockton, Calif. , <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zt�_ 5 �1 <br /> THIS PERMIT EXPIRE$ 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 the San Joaquin Local Health District. 4 <br /> JOB ADDRESS/LOCAATION CENSUS TRACT'' <br /> Owner's Name L ,� � ffwe oz�, ` 1-01FP Phone <br /> Address g. Cit <br /> Contractor's Name " Aee� kAl - EO 6/1p C�i_'<_ License.# ZIrl2- Phone -�ILZ-fff7 <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN j / RECONDITION � DESTRUCTION /_7 <br /> DUMP INSTALLATION / / PUMP REPAIR / / PUMP -REPLACEMENT <br /> Other'1/ r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> SEWAGE, ISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER OOOr� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.- of Well Excavation- <br /> Domestic/private Drilled Dia. df' 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 InformationVz1eFzz IM; [, <br /> E <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP. 'tEPAIR: f / State Work Done f: <br /> .DFgTRUCTION 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 TITLE <br /> (DRW PLOT PLAN ON REVERSE SIDh) <br /> �FORDEPARTMENT 135E ONLY �. A <br /> PHASE I <br /> APPLICATION ACCEPTED .B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASF.-)IUWNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> L__CALL-FOR A-GROUT .INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION... ». T <br /> R H 1426 5/731M <br />