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/ tv <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL.-OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - -la <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUEDr 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 No. . 1862 and the Rule,ss a d Regulations of the San Joaquin Local. Health District, <br /> 3 2-7 <br /> JOB ADDRESS/LOCATION j.Ireat „� nCfQ✓L� �e cid. dY� CENSUS TRACT <br /> CQ <br /> n- r <br /> 1 d r.J 2�f�J Y-1 X ra-1 Phone <br /> Owners Name >� n <br /> Address ..�.._ "3''�� G - - City <br /> Contractor's Name S d1j001 ,R -,#A* _ _ License # l��hone <br /> TYPE OF WORK (Check) : NEW WELL J / DEEPEN -/-7, RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION J I PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER, <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing V <br /> :. Domestic/public Driven Gauge of Casing } <br /> Irrigation T Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> =f Other Other Information <br /> t .. <br /> PUMP INSTALLATION: ContractorL� .--� <br /> Type of Pump vs it lb H.P. t,s <br /> PUMP REPLACEMENT: /�/ State Work Done - <br /> PUMP 'tEPAIR: J State Work Done A c_e 0 4-d 3/ R <br /> ,DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe. Material and Procedure <br /> 4 <br /> I hereby agree to 'coinply 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 /> �t <br /> information is true 'to the best of my koro le a and lief. (� <br /> SIGNED TLE <br /> (DMW PLOT PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCFPTED .BY J. DATE <br /> ADDITIONAL COI NMNTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ADATE ' <br /> .„ CALL FOR A GR OUT INSP CTION PRIOR TO GROUTING D FINAL .INSPECT ON._ <br /> F. H I L 2 6 U Z�13 7 ru"7”P? �^'r GO• 5/731M <br />