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! p SAN JOAQUIN LOCAL HEALTH DISTRICT E <br /> FOR OFFICE US 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ��� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3:3 0 �w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, Date Issued <br /> I. (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 Regulations of the .San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Gs. Y a , ( 2 . jicJ�, .[,iC CENSUS TRACT <br /> Owner's Name G• N css�r_j'Y Phone <br /> Address p City 6. 0 rA <br /> Contractor's Name License #/�-Phone y6p 7-9 ` <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other /_7 <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 J <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 Gravel Pack • - Depth of Grout Seal � <br /> Other Rotary Type of Grout <br /> Other Other Information L r: <br /> PUNK' INSTALLATION: Contractor oxV , <br /> Type of Pump H.P. 7S'- <br /> PUMP REPLACEMENT: / / State Work Done r;'} <br /> FUM? REPAIR: / State Work Done <br /> ,DESTRUCTION 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 />'Einformation is true to :the best of my knowled� d belief; <br /> SIGNEDZZ ITLE �- <br /> D L LAN ON R RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I FI AL INSPEC I0 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION.PRIOR,TO GROUTING AND FINAL INSPECTI69. <br /> E H 14267/7' <br />