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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf. OFFICI: USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> -' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. :S <br /> I <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued, 2/-3-�.5' <br /> �. (Complete In Triplicate) q`fD-o <br /> E Application is hereby madeito the San Joaquin Local Health District for a permit to construct <br /> G and/or install the work hez4n described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 aid the Rules and Regulations of the San Joaquin Local Health District. <br /> 2CP�o uEF CENSUS TRACT <br /> JOB ADDRESS/LOCATIONS �` <br /> Owner's Name Pizone <br /> 7T�(0"?Q <br /> T <br /> Address .� ?1 3 `!�'r _ City <br /> t <br /> Gontractor',s Name LicensePhone� C <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION J <br /> PUMP. INSTALLATION / / '-..PUMP REPAIR .Lkf PUMP REPLACEMENT /rT <br /> O the'r / / O <br /> ( DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' PIT PRIVY <br /> ( SEWAGE DISPOSAL FIELD CESSPOOL/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 <br /> Domestic/public ,. }_ Driven' , Gauge of Casing <br /> Irrigation x-` `Gravel Pack W-- Depth of 'Grout $eal <br /> Other , Rotary Type of Grout C <br /> Il Other Other Information <br /> PUMP INSTALLATION. Contractor y <br /> ^ P. <br /> [ Type of Pump H. - <br /> PUMP REPLACEMENT: / / State Werk Done k _ <br /> PUMP 'REPAIR: ( Jstate Work Done <br /> A ,DF.TRU_C_TION 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 regulatifng we11 ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will ,fu�nish the San Joaquin Local Health District j <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 <br /> TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> 4 FOR DEP4WTMENT USE ONLY � <br /> + PkiASE I f - <br /> APPLICATION ACCEPTED ,BY - <br /> ADDITIONAL COMMENTS <br /> PHASE 11 GROUT INSPECTION t;.� P / INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -- CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />