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OTHER <br />SEWER LINES PIT PRIVY DISTANCE TO NEAREST: SEPTIC TANK <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />FOr-OFFICE USE: = 1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br /> APPLICATION FOR' WELLCONSTRUCTION OR PUMP PERMIT Permit No. Z7-194.0 <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 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 ahd the Rules and Regulations of the San Joaquin Local Health District. <br />.JOB ADDRESS/LOCATION //1 fll /),y),4d&h,/otili <br />Owner ' s Name An3e4rF;LAals2._ Phone <br />Address /1/y6 1/yite. pd Co- <br />Contractor's Name &9-1-dijt.,,DA earl_ to License/002 Phong/ 3 <br />I <br />CENSUS TRACT <br />City <br />SIGNED e l e„1, byldij 1 <br /> <br />DATE <br /> <br />5 /7 3 im <br />TYPE OF WORK (Check): NEW WELL ee DEEPEN 1/ RECONDITION f-T DESTRUCTION CI <br />PUMP INSTALLATION / —PUMP REPAIR -/ [—PUNT REPLACEMENT f-T <br />Other / / <br />INTENDED USE <br /> Industrial <br />Domestic/private <br />Domestic/public <br /> (Irrigation <br />Other <br />TYPE OF WELL <br /> Cable Tool <br />Drilled <br />Driven <br />Gravel Pack <br />Rotary <br />Other <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation r- 1/ <br />Dia. of Well Casing e.,iV <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout <br />Other Information <br />PUMP INSTALLATION: Contractor <br />Type of Pump H.P. <br />Li, State Work Done <br />State Work Done' <br />PUMP REPLACEMENT: <br />PUMP - <br />,DFqTRUCTION 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 <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 />TITLE 7j2Lh4 L-'L <br />(DRAW PLOT PLAN ON REVERSE sib) <br />FOR DEPARTMENT USE ONLY <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHA II GROUT INSPECTION P E Til FINAL INSPECTION <br />INSPECTION BY N\\0,_ 4 DATE INSPECTION BY f _ , DATE <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.