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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0_F.OFFICE USE: 1/ 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 /> 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 / - S CENSUS TRACT <br /> Owner`s Name 'a, Phone <br /> - - -- -- - -- - G7:aC.q�_ <br /> Address /-9 f_L.- -� " - City . . . . <br /> Contractor s Name /LAG Licensed Phoxie <br /> TYPE OF WORK (Check) : NEW WELL ./7 DEEPEN / / RECONDITION_/ / '.DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR'/ / PUMP REPLACEMENT /_7 <br /> Other ./ / - - <br /> DISTANCE TO NEAREST: SEPTIC TANK 6- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 H.P. . <br /> A <br /> -PUMP REPLACEMENT: / /�State Work:Done . <br /> PUMP VPAIR: / / State Work Done . <br /> ,DFIRTRUCTION 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 /> 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 <br /> vJ <br /> -- (DF:kW- PLOT PrM ON 'REVERSE SIDE) -FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATEcat /_S + <br /> ADDITIONIAES <br /> : <br /> OUT INSPECTION P E I AL INSPECTION <br /> INSPECTI DATE INSPECTI Y DATE -Z7- 7 <br /> i - CALL FOR A -GROUT INSPECTION PRIOR T GROUTING AND FINAL INSPECTION. <br /> E H 1426 q/731M <br />