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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI. OF1 CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 /� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � _,5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,3>13_ <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. <br /> JOB ADDRESS/LOCATION <br /> l d_ �S l`a cu P/` S - --- CENSUS TRACT <br /> c�� - _- - <br /> Owner's Name .J rz_ /- .S 4 Phone 77 ?S�� <br /> Address City ' <br /> Contractor's Name License #i A Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /—/ DESTRUCTION /- <br /> PUMP INS ALLATION / J PUMP REPAIR { / PUMP REPLACEMENT— 1-7 <br /> `X w <br /> Other / / [„ <br /> DISTANCE TO NEAREST: SEPTIC TANK V,5- SEWER LINES PIT PRIVY �1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> IF INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation e <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing lj <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> j Other Rotary Type of Grout <br /> Other Other Information <br /> i <br /> r <br /> i PUW INSTALLATION: Contractor CZ5Z <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DF9TRUCTION 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, T 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 /> F information is true to the best of my knowledge and belief. <br /> j SIGNED `V` / l TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />,t PHASE I <br /> APPLICATION ACCEPTED BY DATE ] - 13 - Z9 <br /> ADDITIONAL COMMENTS: �T <br /> SE II GROUT INSPECT ON P46,jEaIILFjNAL INSPECTION <br /> INSPECTION BYT 4LDATE INSPECTION. BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP TION. <br /> E H 1426 5/731M � <br />