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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ffr..�OIFICL USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 T <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No./W- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-,-kl-? (/ <br /> Y . (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, Sark Joaquin <br /> County Ordinance No, 1862 and the-Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Mame r D C /Z C� -0 Phone <br /> Address Jf� f'-� Cityo��'i . <br /> Contractor's Name gy QA License i.1440,Z07Phone <br /> TYPE OF WORK (Check) : NEW;!�WELL . DEEPEN f RECONDITION I_l DESTRUCTION <br /> PUM INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ih <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OIL-WELL CONSTRUCTION SPECIFICATIONS <br /> industrial ; ' Cable Tool Dia. of Well Excavation <br /> T Domestic/private. Drilled Dia. of Well Casing <br /> Domestic/publicDriven Gauge of Casing <br /> - - <br /> ____rr Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout � 62C0GL WIT( <br /> ,! Other Other Information ' <br /> jl . <br /> PUMP INSTALLATION: Contractor <br /> Type` of Pump H.P. I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / /, State Work Done <br /> PFO-TRUCTION 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 /> e <br /> SIGNED o, TITLE &Z/I�� <br /> ��. (DRAW PLOT PLAN ON REVERSE SIDE) <br /> .I F0 D PARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTEDBY <br /> DATE i <br /> ADDITIONAL COMMENT <br /> PHAS I SPE N PHAS ­ AL INSPECTION <br /> INSPECTION BY D T INSPECTION BY , rDATE <br /> CALL FOR A R INS- C'TION PRIOR TO GROUTING.AND FINAL INSP 'TI10 <br /> E H 1426 :` 5/731M. <br />