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i <br /> �- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F.-OFFICE USE: 1601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781' <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE 'ISSUED Date Issued ]f <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 /> t County Ordinance .No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION 'ffy roggiCENSUS TRACT ' <br /> Owner's Name ' & All) Phone ',Y Z/� <br /> Address r } Ld� City Js% fes. <br /> f ,.., ; <br /> r Contractor's Name s � % License �� f / ?'? Phone 'r -�; <br /> j TYPE OF WORK (Check) : NEW WELLDEEPEN '/ / RECONDITION / DESTRUCTION_/ �r <br /> PUMP INSTALLATION J PUMP REPAIR., /—/ PUMP REPLACEMENT /_7 � <br /> i Other / / r <br /> t 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 -`­ __.L�-Cable Tool Dia. of Well Excavation <br /> k - <br /> Domestic/private Drilled Dia. of Well Casing1;Domestic/public - Driven Gauge..of Casings <br /> .."Irrigation Gravel Pack Depth of Grout <br /> Other - Rotary Type of Grout ` ' <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> " Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State work.Done <br /> PUMP `tEPAIR: � <br /> / /. State Wotk' Done <br /> t <br /> DF�TRUCTION OF WELL: Well Diameter -A p oximate Depth <br /> Describe Material and Procedure , , <br /> t <br /> I hereby agree to comply with all lawsMand regulations,of the San Joaquin Local Health District <br /> and the State of California pertaining to or re g we11''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I-.will,�Iurnish 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 latoailedge and belief. <br /> t SIGNED `z-. s« r TITLE ��'.I�s>' <br /> t DRAW PLOT PLAN ON REVERSE SIDE <br /> 3 FOR DEPARTMENT USE ONLY <br /> r <br /> i PHASE I <br /> APPLICATION ACCEPTED .BYr. DATE <br /> I _ / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TTI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1425 5/731M <br />