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f! a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fO�.:OITIZE USL.: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ljpd�p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued �S� <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 Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. `. <br /> JOB ADDRESS/LOCATION (d S R <br /> CENSUS TRACT <br /> Owner's Name G l(1 LL Al r- c' <br /> Phone <br /> Address !U � G -' �.' i <br /> City S r,<,/ <br /> Contractor's Name <br /> - +License ���_6S7Gi Phone <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN / / RECONDITION"/ / —DESTRUCTION /_7 <br /> POther <br /> UMPINSTALLATION PUMP REPAIR/ / , ? REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> � SEWER LINES PIT PRIVX <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TXPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Tell Excavation <br /> ' V, Domestic/private Drilled Dia. of Well Casin <br /> Domestic/public Driven g <br /> ,j_ Irrigation Gauge of Casing <br /> Gravel Pack Depth of Gro <br /> Other Rotary ut Seal <br /> Type of Grout <br /> Other Otherrinformation <br /> .I <br /> iP ---------------- <br /> UMP INSTALLATION: Contractor <br /> Type of Pump C <br /> H.P. _f <br /> PUMP REPLACEMENT: State Work Done T <br /> PUMP `tBPAIR: <br /> / / State Work Done , <br /> ,DFgTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure a ; Approximate Depth <br /> � r <br /> I hereby agree to comply with all laws and regulations of the Sart Joaquin Local Health Distract <br /> and the State 'of California pertaining, to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a newwell, I will furnish the San Joaquin Local Health District ash <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in"use. The above <br /> information is true toathe best of my knowledge and belief. <br /> SIGNED <br /> TLE <br /> (D PLO ON REVERSE SI <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BX <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHAS II/ INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY <br /> t <br /> ATE # <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ,�_ , <br />