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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E,6�.,:OIF7FICE USE: 1601 E. Hazelton Ave, , <br /> Stockton, Calif. <br /> -`--� " Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � 5394� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /�-Z3- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> n compliance with San Joaquin; <br /> and/or install. the work herein described. ' This application is made i <br /> County Oxdina�ice No. 1862 and the Rules and Regulations of the San Toaquin� Local��- �ealth District. , <br /> t 3 lLiLL� <br /> te[; CENSUS TRACT <br /> JOB ADDRESS/LOCATION - <br /> NoRTH OF E-B WAY <br /> Phone - <br /> Owner's Name HE <br /> City R EDX <br /> R <br /> Address <br /> License # 116x22 Phone l <br /> Contractor's Name - <br /> i TYPE OFYWORK (Check): NEW WELL /X/ DEEPEN/ / RECONDITION DESTRUCTION DESTRUCTION I�T N <br /> iI PUMP INAL <br /> STLATION / UMP/ PREPAIR PUMP REPLACEMENT / <br /> Other <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 <br /> Cable Tool Dia. of Well Excavation 2 " <br /> n <br /> Domestic/private Drilled Dia. of Well. Casing 1 <br /> Domestic/public <br /> Driven. Gauge of Casing <br /> X Irrigation X Gravel Pack Depth of Grout Seal , <br /> Other' ^ Rotary Type of Grout <br /> Other Other Infdrmation . Slab-by Owner-- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: �!] State Work Done <br /> A PUMP UPAIR: / / State Work Done <br /> f Approximate Depth <br /> ,DFgTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure . <br /> #} r <br /> i and regulations of the San 3oaquin Local <br /> I hereby agree to comply with all laws Health District <br /> i' 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 F <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 <br /> �f <br /> SIGNED D W PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 4 j;473 - <br /> APPLICATION- ACCEPTED BY t <br /> ! K" ADDITIONAL <br /> CONSENTS: <br /> PHASE II UT INSPECTION P II / AL INSPECTION <br /> INSPECTION BY DATE _ INSPEC ATE - <br /> _. CALL--FOR-A- GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />