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_ SAN JOAQUIN WCAL HEALTH DISTRICT 5 <br /> rryf. OFFIC_ �k SL,` -- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> " .PPLTCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued �t5 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct s1 <br /> and/or install the work herein described.. This application is made in compliance with San jbaqu r <br /> r County Ordinance No. 1862 §Lnd theRules and Regulations of the San Joaquin. Local Health Di 6ict. <br /> JOB ADDRESS/LOCATION SUS TRACT <br /> Owner's Name 0 <br /> d Phone ;�j73?. 7 0!� , <br /> Address i L `T'/ fid city <br /> • •-• �.-,_.._ ,,... — <br /> Contractor's Name L License #.:F10jp3 Phone Q <br /> E OF WORK (Check) : NEW WELL a/- DEEPEN ,/—/ RECONDITION /_/ DESTRUCTION' /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD " ' CESSPOOL/SEEPAGE.FIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Xndustrial Cable Tool Dia. of Well Excavation /fa <br /> _ Domestic/private Drilled. Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Or <br /> Other --�-X Rotary Type of Grout , <br /> �— Other Other Information <br /> PUMP INSTALLATION: 0&a b 5-76/ <br /> Contractor - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done /'10 CHANGE~ _ V-� -a <br /> PUMP UPAIR: / f State Work Done F. ` <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 /> ,d <br /> the -State of California pertaining to or regulating well construction. Withif FIFTEEN DAYS <br /> --�kr- ,60"4oletion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> .ERS REPORT of the well and notify them before putting the well in use. The above <br /> a is true to the best of my knowledge and belief. <br /> .•, . <br /> 'SIGNED _ TITLE <br /> (DRA17 -ffLM PLAN ON REVERSE SIDE -�* <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED_ BY E <br /> ADDITIONAL COMMENTS: . llS <br /> PHASE II GROUT .INSPECTION P /FINAL INSPE 0 Q <br /> SPECTION B DATE INSPECTION BY DATE 70 <br /> CALL FOR A rF`� INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />