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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL 'OFFICE USE: -- 1601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. zly__=:5_3.j <br /> _ THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 4,0,/ 2_o_v--t30-- 13 <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 CENSUS TRACT <br /> Owner's Name arid I Phone 59/.1—/ <br /> ;; v <br /> Address r741-,qr. -- city \ <br /> g3t�'7 s 7 d <br /> Contractor's Name License # 7 Phone R �� 5_4�- <br /> TYPE OF WORK (Check) : NEW WELL &I DEEPEN/ / RECONDITION �/ DESTRUCTION /WT <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? N <br /> Other Y-1 ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <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 i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: / / State Work Bone <br /> PUMP •tEPAIR: / / State Work Done <br /> ,DFgTRUCTION OF WELL: Well Zjameter 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 /> j SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -Hy DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS ' I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,- 11-1 <br /> - CALL-FOR A GROUT INSPECTION PRIOR TOGROUTING AND FINAL INSPECTION. <br /> _. <br /> line _ .. . . _.a.. , 5/731M <br />