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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fr—lor.7OFFICL 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 <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 Jgaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local, Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name XIN RAMOAl bb <br /> Phone <br /> Address 2-6 ;-60 ' W 61-441 R d'DA/ � D City S <br /> Contractor's Name License 4E <br /> lei Phone 4rG <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/ / RECONDITION / J DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other PUMP REPLACEMENT /- <br /> / / <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 Excavations <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack <br /> Other Depth of Grout Seal <br /> �•' <br /> Rotary Type of Grout U <br /> Other Other Information ' f <br /> PUMP INSTALLATION; Contractor <br /> Type. of Pump &IOel <br /> Hi <br /> .P. <br /> PUMP REPLACEMENT: / / State Work Done t <br /> PUMP 'ZEPAIR: State Work Done <br /> .DFfiTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all Laws and regulations of the San Joaquin Local HealthDi <br /> I will furnish the Sstrict <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> e an Joaquin Local Health District a <br /> after completion of my work on a new well, . <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 /> SIGNER �y <br /> TITLE Gimme. <br /> (D W PLOT PLAN ON REVERSE SIDE) <br /> PHASE I "— <br /> FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO- GROUTING AND FINAL INSPECTION. A e <br /> E H 1426 <br />