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171 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For."OFFICE USE: 1601 E. Hazelton Ave.., Stockton, Calif. <br /> . Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT• Permit <br /> E ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 5�& <br /> (Complete In .Triplicate) <br /> Application is hereby inade 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 Sant Joaquin <br /> County Ordinance .No. 1862 and the Rules and Regulations of the San Joaquin Local: llealfh. Dis�rict. <br /> E JOB ADDRESS/LOCATION DD CENSUS TRACT Y' <br /> t <br /> Owner's Name `� � �/� - � <br /> _� f7 _ ��`�� Phone <br /> Address �`� 'D �J � ^r City - <br /> --J <br /> Contractor's Name V , i ;:� ��d lrj 4t -w, �. CJ, License 4�/�/!� 30hane y/ � �~? <br /> ' w <br /> f <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PLV REPAIR / / PUMP REPLACEMENT / <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC- TANK 2�-4® SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Z.0,0 ` CESSPOOL/SEEPAGE PITT OTHER <br /> NZi <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS- } " <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack, Depth of Grout Seal 1�;-o t r p/u s •'; <br /> Other ��� Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> � s <br /> Type of Pump _--_ .' H-.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: <br /> / / State Work Done <br /> 4 <br /> ,DFSTRUCTION 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 E <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above 4 <br /> information is true to .the -best of my knowledge and belief. j <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN-.ON REVERSE SIDE} i <br /> FOR DEPARTMENT USE ONLY f. <br /> PHASE I E <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ;I GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BDATE f 7� INSPECTION BY Q. DATE <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E -5/731M <br /> H 1426:= - {: <br />