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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS'. OFFICE: USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued L��3 <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 Regulatio s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT �]-- <br /> Owner's Name e . Phone <br /> Address 9361 E . Melton City Manteca. Cal. <br /> Contractor's Name Co Inc License # 116322 Phone 522-56�31 <br /> 2 50n i <br /> TYPE OF WORK (Check) : NEW WELL /g/ DEEPEN/—/ RECONDITION /% DESTRUCTION I—T <br /> 'a PUMP INSTALLATION I / PUMP REPAIR ,/—/—PUMP REPLACEMENT /_ <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TJV�K SEWER LINES PIT PRIVY <br /> 2 . . SEWAGE DISPO AL FIELD ', CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE Al, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial- -Cable Tool Dia. of Well Excavation _ rte` � 1 <br /> _X Domestic/privateDr lled. ,r Dia. of Well. Casing Err G <br /> Dome6tic/public Driven - Gauge of Casing 12 GA <br /> Irrigation' Gravel Pack Depth of Grout Seal 501 <br /> Other �- Rotary Type of Grout BPt�t� �1 tom_ <br /> Other Other Information Slab by owner <br /> PUMP INSTALLATION: Contractor p <br /> Type of Pump S H.P. <br /> r <br /> PUMP REPLACEMENT: i V State Work Done <br /> PUMP UPAIR: _ /% State Work Done <br /> ,DFqTRUCTTQN OF WELL: Well Diameter _ � _ Approximate Depth <br /> Describe Material and Procedure I <br /> I <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 r _ ` TITLE i <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ! <br /> FOR D TMENT USE ONLY <br /> PHASE I __2 <br /> APPLICATION ACCEk'TED . DATE <br /> ADDITIONAL C01%R ENTS: <br /> P GROUT IiSPECT S �II �/ �N �INSPECTION.INSPECTION. BY ( DTE p .r INSPEC <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />