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kAO <br /> YV`ISL�.. SAN JOAQt.IIN LOCAL HEALTH DISTRICT <br /> r�OF.:OFFICL USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> .I Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.��,�.�•J <br /> THIS PERMIT. EXPIRES jr YEAR FROM DATE ISSUED Date Issued <br /> -- ' (Complete In Triplicate.) <br /> Application is hereby rude toithe San Joaquin Local Health District for a pe6tmit to construct <br /> and/or install the work herein described. : This application is made in compliance with San Joaquin <br /> County Ordinance No:�1662 a%ndIthe Rules and Regulations-of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION��d// r /r(/1 D� � /'l• CENSUS TRACT <br /> Owner's Name_,���G(f - �I CQ�' - _� ,i -- - "- -- - - - Phone " <br /> Address ' Z. Q = - City " �� <br /> . —� <br /> Contractor's Name �rT ,� / License Phone�,V�W7 r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION I / DESTRUCTION /_7PUMP INSTAL" ATION PUMP REPAIR '/ / PUMP REPLACEMENT /7 R <br /> Other',/_/ <br /> bl " <br /> DISTANCE TO NEAREST:? SEPTIC�TANK SEWER LINES PIT PRIVY <br /> SEWAGE t ISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE O ALL CONSTRUCTION SPECIFICATIONS NO <br /> Industrial l Cable Tool Dia.. of Well Excavation <br /> ,,�—Domestic/private J Drilled Dia.' of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation Gravel "Pack Depth of Grout Seal <br /> Other ;.l Rotary Type of Grout _ fdcfl <br /> Other Other Information <br /> w d <br /> PUMP INSTALLATION: Contriactor ZKZL= O al" <br /> Type of Pump ne,4 41 H.P. ' / <br /> I� <br /> PUMP REPLACEMENT: / /; State Work Done <br /> PUMA' 7EPAIR: / / State Work Done <br /> x9TRUCTION 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 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 /> oop <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PEASE I <br /> APPLICATION ACCEPTED BY j 9, DATE .Zfa _ <br /> ADDITIONAL C4Pi3ASTSII GROUT TNSPECTIO <br /> ... fiVP.GP <br /> PHAS I I/FINAL INSPECTION s <br /> INSPECTION BYTE 1,, INSPECTION BY DATE y <br /> CALL FOR A`GROUT INS] TO GROUTING AND FINAL INSPECT N. <br /> FECTION. ' <br /> E H 1426 5/731M <br />