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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Off. <br /> OFFICE USE:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-1V--a7a W � <br /> TRIS;PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t.._ (Complete In Triplicate) <br /> Appli,6Ati�ibn 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 Sari Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Disprict. <br /> I <br /> JOB ADDRESS/LOCATION C �e � 07,SS /+ ENSUS TRACT <br /> Owner's Nance �,�,, Phone <br /> - - - <br /> I Address 6 / ..r. // ��/��IIvice.� City 7a- <br /> Contractor's Name License Phone 'l�fe <br /> TYPE OF WORK Check): NEW WELL /—/ DEEPEN/ / RECONDITION /% DESTRUCTION <br /> PUMP INSTALLATION / / PLW REPAIR/ / PUMP REPLACEMENT /7 <br /> i 0 th I / . <br /> _ t <br /> DISTANCE TO NEAREST: SEPTIC TANK_ N • SEWER.LINES PIT PRIVY <br /> F SEWAGE DISPOSAL FIELD " "CESSPOOL/SEEPAGE PIT OTHER <br /> r 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 i Rotary Type of Grout <br /> Other Other .Information ' <br /> I`I 4 <br /> PUMP INSTALLATION: Contractor <br /> Types of Pump H.P. <br /> PUMP REPLACEMENT: j /; State Work Done <br /> PUMP 'PAIR: /I State Work Done ' 4 <br /> 5 <br /> ,DESTRUCTION OF WELL: Well Diameter /Z Approximate Depth <br /> Describ Material Proced -f <br /> IE <br /> I hereby agree to comply wirth all laws a egulnt ons of a 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 t•e well and notify them before putting the well in use. The above <br /> information is true o the-best of my knowledge and belief. <br /> a ` <br /> SIGNED A.. a���II TITLE . G��/ — -- <br /> uD (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> I <br /> PHASE I <br /> APPLICATION ACCEPTED .SY I, DATE yJ— <br />' ADDITIONAL C0101E'NTS: <br /> PHASE II G O I PL'CT ON V PHA E /FINAL INSPE IO <br /> INSPECTION BYd�� DATE INSPECTION BY DATE .- � <br /> `__CALL-FOR-A••GROUT�INSPECTION•PRIOR -TO GROUTING AND FINAL INSPECTION.' GC <br /> E H 1426 0 5/731M <br />