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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> COF_011FICE' USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zj T <br /> _ THIS PERMIT EXPIRES 1 YEAR FROM ]TATE ISSUED Date Issued - -7 <br /> r�L..4•c 14- -rul�_a,2�, (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. k <br /> JOB ADDRESS/LOCATION - C NSUS TRACT <br /> Owner's Name Phone E--YK 91—C <br /> Address City " Z <br /> Contxa tar'`s Name - - - --_�[:Gr�--� - ; .- - License # 3 a"Phone , <br /> r' <br /> TYPE OF WORK (Check): NEW WELI.--�DEEPEN ./ / RECONDITION I_f DESTRUCTION l�T <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT 17 <br /> 0 Cher / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /moo PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> INTENDED USE..' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �' W <br /> -- --- Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> othery Rotary Type of Grout <br /> Other Other Information U <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work .Done <br /> PUMP UPAIR: # / / State Work Done <br /> DFsTRUCTION OF WELL: Well. Diameter _ Approximate Depth ` <br /> - a <br /> Describe Material and. Procedure <br /> 5 <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 /> 14ELL DRILLERS REPORT of .tie 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 .. t d TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> P1iASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SEI I/FINAL INSPECTION ` <br /> INSPECTION- BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT "INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. <br /> 5/731.M <br />