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SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> C_. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED Date,Is'sued- <br /> �,. <br /> ,j (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 herePin described. '. This application is made in compliance with San Joaquin <br /> County Ordinance .No. ]862 aade es d Re gya on of the San Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATION <br /> i9C CNe /� p,� <br /> n n L IV Z2CENSUS TRACT <br /> Owner's Name _ <br /> -�gduic=g-•rgc+�----- Phone <br /> Address � .A/�.tc✓— �%j]/ / City <br /> 61�!_ �i� 9"!306 <br /> _1rV v_— <br /> Contractor's Name �/I lR/GfiBn /QX7- Iar4 ._ License hone <br /> Cj <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION /_7 DESTRUCTION (7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,�20 . SEWER LINES/j�v_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /6 D CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool Dia, of Well Excavation <br /> ___2Domestic/private =Drilled Dia. of Well Casi'ng.' <br /> �- 'Domestzc/pub3lc-- - �- Driven= -- -;--Gauge-of4Casing- T eI - q_�� <br /> Irrigation 1 Gravel Pack Depth of Grout 'Seal (" <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PITINT INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /_7 State Work Dope �-.. <br /> ,DFcT U TION OF WELL Well Diamete , Gee!' we%l dill � p�SI Approximate Depth <br /> Descri a tercel d._Pso=re, <br /> I hereby agree, to comply with all laws and r gulations' o 'EhOf 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 /> SIGNED (� (7/P ( /� tl _ - TITLELf /Z _ <br /> y <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F <br /> PHASE I R DEPARTMENT USE ONLY <br /> ��5 <br /> APPLICATION ACCEPTED BY /, �A DATE <br /> ADDITIONAL CO2,^ifENTS: <br /> PHA II OU INSPECTI N PHASE I I/ AL INSPECT 0 ' <br /> INSPECTION BY DATE <br /> -L INSPECTION BY DATD <br /> - CALL FOR, A GROUT ,INSPECTION-PRIOR TO.GROUTING AND FINAL INS TION.PLt� <br /> E H 1426 ;- <br />