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1 <br /> D �SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR`0 FICE USE: r, 16031 E. Hazelton•Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: 7)ILP <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ' Date Issued <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/LOCATION' <br /> `7 „I CENSUS TRACT <br /> Owner's Name Phone <br /> Address J.7 City -r` - <br /> r Contractor's Name License # /Z2.?73 Phone G GSR <br /> TYPE OF WORK (Check)•• NEW WELL DEEPEN /? RECON _ — _ <br /> DITION F7 DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR Z/ PUMP REPLACEMENT /_7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK =SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ,!" . CESSPOOL/SEEPAGE�PIT OTHER , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing g +� <br /> Domestic/public Driven Gauge of Casing oall J-1 <br /> _ <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 H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br />-PUMP_REPAIR.: ., State-Work ..Done. <br /> ESTRUCTION OF WELL: Well Diameter <br /> -p 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 j <br /> information is true to the best of my knowledge and belief. <br /> I SIGNED � �{' _ _ .,u 14 1,0 TITLE � 2� <br /> DRAW PLOT P AN ON REVERSE SID _ <br /> G <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPT BY . DATE <br /> ADDITIONAL COMMENT . qn¢y� ; 4.oQ� <br /> PHASE II GROUT INSPE TIO PHASEIII/FIIqAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY FIT DATE ,,;P <br /> CALL FOR A GROUT INSPECTION PRIOR TO /GROUTING AND FINAL INSPECT ON• <br /> E H 1426 /j,/,, C� i�rZ Z � vttl i� �" •. 0),A"J �4 w 1,6.?U 2 im 105 <br />