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(t SAN JOAQUIN LOCAL HEALTH DISTRICT [y <br /> I?®rOFFICE USE: 1601 -E. f�atelton Ave. , Stockton, Calif. CA telephone: (209) 466-6781 l! � r <br /> APPLICATION 'POR WELL CONSTRUCTION OR PUMP PERMIT Per _ Sr <br /> �o. <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 Di.sprict. <br /> JOB ADDRESS/LOCATION 6z-� <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address �c�/ /V s dpi City ' <br /> Contractor's Name - �..t) License # / 71J phone )---A <br /> z <br /> TYPE OF WORK (Check) : NEW WELL/% DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /-J <br /> AL <br /> PUMP INSTLATION REPAIR/ J PUMP REPLACEMENT /_7 i <br /> Other I I — <br /> 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 Cable Tool Dia. of Well Excavation <br /> --,K Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> —�K Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 4 <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump - / H.P. <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP : /% State Work Done <br /> ,DRgTRUCTION 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 /> information is true to the best-••ofmy k wledge and)belief.. <br /> SIG N'D off ITLE <br /> 7T a <br /> ..� W__-PLOT PLAN ON MWERSE SIDE) <br /> V FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE � Ar i <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE • A ? <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br />