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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OI' ICE USE: . 1601 E. Hazelton'_Ave. , Stockton, Calif. <br /> Telephone: % (20$0%,'466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7g-4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a_.zo 2,� ' <br /> (Complete In Triplicate) t <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 Sart Joaquin , <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. ; <br /> j <br /> JOB ADDRESS/LOCATION 1. CENSUS TRACT 3 <br /> Owner's Name ea— - Phone <br /> Address ..E� _S f �'t, D !//_S City <br /> r! <br /> Contractor's Name A`�er c-s 7'1 C --/O G"� ._ License # Phone <br /> r "' RECONDITION -'/ /- DESTRUCTION`--/�""' - �"'�"' <br /> TYPE .OF.WORK (Check ; NEW WELL � DEEPEN '/ /„ _ I <br /> PUMP INSTALLATION <br /> —PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / <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 _ Cible• Tool Dia. of Well Excavation <br /> Domestic/.private _ Drilled Dia. of Well Casing <br /> Domestic/public ?---Driven Gauge of Casing <br /> Irrigation M Gravel Pack Depth of Grout Seal l <br /> Other ;Rotary. Type of Grout <br /> r.t)ther` . Other Information <br /> . l <br /> Ez- 4"PUMP'INSTALLATION: Contractor � . .. <br /> HP <br /> Type of Pump [.,,� . <br /> J <br /> PUMP REPLACEMENT: F_-'/�/ State Work Done <br /> PUMP `tEPAIR: %/d State Work Done <br /> ,DF-,TRUCTION OF WELL: . Well Diameter I Approximate Depth <br /> j 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 thein before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. } <br /> TITLE <br /> SIGNED <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I : DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> ` <br /> PHASF, II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL k'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br /> E H 1426 "' <br />