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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i'OF..OFIIcE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. l-L <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 Joaquir <br /> County Ordinance No. 1862 and the Mules and Regulations of the San Joaquin Local }lealth District. <br /> JOB ADDRESS/LOCATION I%X72 CENSUS TRACT <br /> Owner's Name Phone <br /> E <br /> Address - _ _ O / Al /Y/ _ City. "Zfmm -C. <br /> I <br /> E � <br /> Contractor's Name �Q �1�, 2-2f� License Phone '7e,,s a S� <br /> F <br /> .It_ <br /> s- <br /> TYPE OF WORK (Check):'111 NEW WELL _.L( DEEPEN / / RECONDITION f_1 DESTRUCTION /-7 <br /> ill PUMP INSTALLATION PLT2P REPAIR '/ / PUMP REPLACEMENT /_ <br /> .I. <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TLNK SEWER LINES PIT PRIVY <br /> ;'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE-OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Y, Cable Tool Dia. of Well Excavation /-z— <br /> Domestic/private Drilled Dia. of Well Cawing <br /> Domestic/public; Driven Gauge of Casing / -Z.. <br /> G <br /> Irrigation Gravel Pack Depth of Grout Seal Pe C <br /> Other Rotary Type of Grout ,.-F� <br /> Other Other Information , <br /> N ' <br /> 6 <br /> PUMP INSTALLATION: Contractor 2 S~7 <br /> Type of Pump-,, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `REPAIR_: I / 'State Work Done <br /> ,DF'0-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> „ Describe Material and Procedure f <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Stare 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 /> a SIGNED r T� Je � <br /> E <br /> (DRAW LOT PL ON REVE E SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY � DATE <br /> ADDITIONAL COMYENTS: <br /> PHASE I GROUT INSPECTIO PHASE I /FIQZ INSPECT ON <br /> INSPECTION BY DATE -7 INSPECTION BY DATE <br /> 1--CALi:•-FOR;-A-,GROUT----INSPECTION•-PRIOR-TO GROUTING..AND..FINAL..INSPECTION. �. . . . �.. ..�:.r <br /> ti E H 1426 '5�731M �:� <br />