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SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> "ICL USE: 1601 -,E. 1�aBelton Ave. , Stockton Calif. <br /> � iephone: (209) 466--6781 <br /> APPLICATION 1�bR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 Joaquin, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> D <br /> JOB ADDRESS/LOCATION '�L CENSUS TRACT <br /> Owner's NameJ .lf�� t►rs 1� - - Phone <br /> Address 1D,03 / Al c3 kdo,660A. , City C � d <br /> Contractor's Name License ?3-J Phone 7zun <br /> J <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION Z/ PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other 1_7 <br /> ;I <br /> DISTANCE TO NEAREST: SEPTIC TALK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> . i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> )C Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �W, Irrigation Gravel Pack Depth of Grout Seal -; <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP / / State Work Done <br /> DF�TRUCTION 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 <br /> WELL DRILLERS REPORT of .the well and notify them 'before putting the well in use. The above <br /> F information is true to the best--of. my k wledge and belief. i <br /> i <br /> SIGNkD � ITLE <br /> W L T PLAN ON WVERSE SIDE) <br />! c FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION ` <br /> INSPECTION BY DATE INSPECTION BY DATE e - A .'7 <br /> - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> TT + i nr I7�-1M <br />