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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �F. 017FICL US :: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a-/S94/ <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 1� d the Rules and Regulations of the San Joaquin Local Health Disprict. <br /> /,3 OP 3�- / <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address _47 Fill—- 117lt.4V 217 City <br /> Contractor's Name � j �/����� d ,ter License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN '/% RECONDITION / / DESTRUCTION %f <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C7� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Z� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ <br /> Domestic/private Drilled Dia. of Well Casing /;P— <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal r <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DFv-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lams 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 alcove <br /> information is true to the bes of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CO1,MNTS: <br /> PHASE TI GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY I DATE INSPECTION BY r DATE 7 <br /> CALL FOR-,-A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E x� z6.:a: rF :. . — . 5/731M <br />