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SAN JO,AQUIN LOCAL HEALTH DISTRICT <br /> FOF. ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued7-7-3 <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 ,Jo. aquin <br /> County Ordinance No. 1862 and the Reales and Regulations of the San Joaquin Local Health Disprict. <br /> !- L ebuw,u 111) - I <br /> JOB ADDRESS/LOCATION Sf o ' Po7�1�0� S/Dv�+�l /yrl.— �`� 2414,_s. CENSUS TRACT ` <br /> �S ova v t9 X <br /> Owner's Name 51`�ac p Phone <br /> Address 7 City SJ7��c 77� <br /> Contractor's Name License # Phone ' <br /> I <br /> r <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /? j <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /-T <br /> Other <br /> IV �A ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER? <br /> f r I <br /> INTENDED USE TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ' <br /> - - <br /> Domestic'/private Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other. Rotary Type of Grout <br /> �`roal,y,Si`ca I f, a c,S Other Other Information :w <br /> PUMP INSTALLATION: Contractor F <br /> r., Type of Pump.- y H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP—'tEPAIR.: - / /-,-State Work .Done <br /> DFCTRUCTION OF WELL: Well Diameter .9 a Approximate Depth /oo <br /> Describe Material and Procedure{ C_ Y 21 Z!Z <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 be"f my knowledge and belief. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> I �'TiiASE I <br /> APPLICATION ACCEPTED BY DATE Z�f <br /> ADDITIONAL CONXENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ._. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL -INSPECTION. <br />