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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS'. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,Z - <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6751 <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 rude in compliance with San Joaquin <br /> County Ordinance: No. 1862 and the Rules and Regulations of the San Joaquin Local Hellth District. <br /> JOB ADDRESS/LOCATION d rp [, d io , <br /> rD 1. S CENSUS TRACT <br /> p ,_.._y. <br /> Owner's Name Phone _ ?S� <br /> Address 4 <br /> City <br /> Contractor's Dame - <br /> L�� e \License # Phone cl hpye. <br /> TYPE OF WORK (Check): -NEW WELL/ / DEEPEN '/_/ RECONDIT10 / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /V PUMP REPLACEMENT / 7 <br /> Other / ! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ?IT PRIVY <br /> SEWAGE�DISP08AL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED` USE � TYPEOF.WELL b <br /> C _- __ CONSTRUCTION SPECIFICATIONS <br /> Industrial I i�. Cable Tool Dia. of Well Excavation � <br /> DQmesti4/private , tb''' led Dia. of Well Casing Gf <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation 1 .,�Gravel, Pack Depth of Grout Seal <br /> --- Other „ .. Rotary Type of Grout <br /> t��h e" Other Information <br /> PUMP INSTALLATION. <br /> Contractor - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Rorie ' <br /> PUMP 'REPAIR: _/ / Stale Work Done _-- <br /> .DFsTRUCTION OF WELL: Well Diameter c� Approximate Depth �Q <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 Statelof California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after comple. - _af_my work_on_a,tnew.well,_I will furnish the San Joaquin Local Health District a <br /> WELL DRI.L REPORT of the well(aAd notify them befpr p t ing thewell i .n-UseThe above <br /> infarmatn 's tr to the bestjof.,my knowledge4and belief. <br /> Y j �f <br /> SIGN � fR'! <br /> TITLE Ct f/j r <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Gam' <br /> APPLICATION ACCEPTED -BY DATE 6 <br /> ADDITIONAL CO*MNTS: f <br /> PHASE II GROUT I PECTION PHA II/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION B DATE <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP CTIO f <br /> E H 1426 / <br />