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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �'OF.:03?i"IGk: USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZI- /a�A.,' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r'Z5— I <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS f LOCATION2 coo S p/ !_= G N CENSUS TRACT <br /> Owner's NameN 7 l} � S C� Phone 2 ,3 /-.20 2 / <br /> Address -3 e 5 /V [�t/2 L /V City S 7/'Al <br /> Contractor's Name a License #,2 5�7 Phone "C4`' . <br /> TYPE OF WORK (Check) : NEW WELL /Y/ DEEPEN RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / Pi,`MP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK loos' SEWER LINES PIT PRIVY Gs <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER A1 " <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <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, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ S 13 _ H.P. ' I% <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DF-'TRUCTION 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 /> I 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 /> 1 SIGNED /TLE c <br /> DRAW PLOT PUN ON REVERSE SIDE <br /> F EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE J <br /> ADDITIONAL COMMENTS• <br /> PI E GROUT INSPECT PHASE ./FI i SPECTION <br /> INSPECTION BY ATE INSPECTION BY ATE ,.. G�- <br /> CALL FOR A GROUT INSPECTI N PRIOR TO GROUTING AND FINAL INSPECTION. '] M <br /> .-. ry + 1n1 5/'1 31m <br />