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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FA OFFICE USE: 1601. E. Hazelton Ave.—Stockton, Calif. <br /> r' Telephone: (204) 466-6781 t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES .l-.YEAR'FROM DATETISSUED Date Issued -/Z /, <br /> (Complete In Triplicate) <br /> Application is hereby made- to the San Joaquin Local Health District for a permit to construct j <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 /> T2 .3 :S <br /> .TOB ADDRESS/LOCATION d�06rl7U4 CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name t_1 0 c,�_ License # Phone <br /> N € <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /�. RECONDITION /� DESTRUCTION f f - <) <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT / f W <br /> Other /_7 �n <br /> . i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERi <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS P <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/pdblic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout r <br /> Other Other Information ' ' <br /> PUMP INSTALLATION: Contractor � t12 C� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / /` State Work Done <br /> PUMP REPAIR; r <br /> / / State Work Done ., <br /> I <br /> ,pESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <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 j <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 i �} � 'TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION- BY. DATE 1-�-� INSPECTION BY DATE �s 7 — <br /> CALL_ FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 0 <br /> E H 1426 1 ' 1AIke®ae ja/` 14 GJ 4172 1M <br />