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i. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE .1601 E. Hazelton-,;,Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a D <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 <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 Joaquir <br /> County Ordinance No. '1862 and. the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION, "jyx�e CENSUS TRACT <br /> Owner's Name : Phone �3C <br /> Address City -- <br /> ' f License �� 2 Phone 3 C <br /> Contractor's Name IL)_ L-? <br /> TYPEWORK (Check) : NEW WELL /� DEEPEN3/, // RECONDITION DESTRUCTION /? <br /> PUMP INSTALLATION % /—PUMP REPAIR , REPLACEMENT /_7 <br /> Other <br /> { <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 4 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Other Rotary Type of Grout _ _ _ cl <br /> Other Other Information ;F <br /> PUMPINSTALLATION: Contractor <br /> Type-o Pump— - - -— -�.a H.P. / <br /> PUMP REPLACEMENT: / / State Work Done JC <br /> PUMP REPAIR.° �. . ,.. State .Work 3one�, _ . . <br /> • 4 <br /> ,DESTRUCTION_ 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 /> SIGNED -ti✓" TITLE 2 O <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i ✓ FOR DEPARTMENT USE ONLY <br /> i PHASE I - <br /> APPLICATION ACCEPTED BY DATE y��L��� — <br /> ..ADDITIONAL COMMENTS: <br /> PHASE II IN PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE 7— <br /> ' CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> Z H 1426 7172 1M <br />