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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> iOF. OFFICE 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 /> Applicatio s ere y 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 ?3 7� a ry a a z& CENSUS TRACT f <br /> W <br /> Owner's Name 67P0^9-e Y/m 4-ceti C-41i' l-r r Phone 36,Y- la 612 <br /> Address 12 7 6 Ae-a M e o Kd City A�QT o <br /> Contractor's Name A, /'l- e�rojy (.0 ed L >/-V License #Phone' �- <br /> �/ S <br /> TYPE OF WORK (Check) : NEW WELL A �DEEPEN / / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / W REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ able Tool Dia, of Well Excavation _1 2 " <br /> Domestic/private Drilled Dia. of Well Casing f " <br /> Domestic/public Driven Gauge of Casing :a- <br /> _/„_,--rrrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout l <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor =� , [r-i^n_C (,y p �[ �, ,,�(� y r �,V C <br /> Type of Pump �,S;,v H.P. 71/L <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DFgTRUCTION 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 /> [JELL 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 /> SIGNED ,yam TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PdASE I / <br /> APPLICATION ACCEPTED BY DATE Z,2— <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTIONPHASE II/FIAIAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT IO <br /> E H 1426 - 5/731M <br />