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j� SAN JOAQUIN LOCAL <br /> FOR OFFICE USE: HEALTH DISTRICT <br /> 1601 E. Hazelton-Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES-.I YEAR`FRON_ DATE ISSUEDDate Issued <br /> (Complete In- Triplicate) <br /> Application is hereby,made `to the.rSan. 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 /> JOB ADDRESS/LOCATION Q <br /> C CENSUS TRACT <br /> Owner's Name r 4 • /- Phone (C2 <br /> Address ; City <br /> Cj 01 — <br /> Contractor's Name 1 <br /> _. oe <br /> License # Lp, Phone t tiC3 � <br /> TYPE OF WORK (Check) : NEW WELL /X�DEEPEN ./)// RECONbftION /_/ DESTRUC IQN /_7 <br /> Y <br /> PUMP INSTALLATION / UMP`REPAIR <br /> other PUMP REPLACEMENT /? <br /> I I =�. <br /> DISTANCE TO NEAREST: SEPTIC TANK �--SEWER L�NES� PIT PRIVY <br /> SEWAGE DISPOSAL FIELDQCESSPOOL/SEEPAGE PITOTHER <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION.SPECIFICATI S <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private " Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 6 <br /> Irrigation Gravel. Pack Depth of Grout Seal d"! /1•�-z.c <br /> Other <br /> 2!<_ Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contracto <br /> TYPe of u "p _ H.P. .m+ <br /> PUMP REPLACEMENT: �. `/ / ,State Work.-Done <br /> PUMP .REPAIR-: .. ., .,�_/ti/`_,,.S_tate-work_Done, _ <br /> DESTRUCTION O '1WELL:, . Well .Diameter. Approximate Depth <br /> Describe Material and Procedure �A <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 anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well andtnotify them before putting the well in use. The above <br /> information is true _t-o-' (knowledge and belief. <br /> SIGNEDCAI LCff=C�. <br /> "'- -?ODRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY x f <br /> APPLICATION ACCEPTED BY, N DATE <br /> ADDITIONAL' COMMENTS: <br /> PHASE I.1 GROUT INSPECTION FHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE t f INSPECTION BY DATE - -�7g„' <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. kd� <br /> E H 1426- ' - - /72 1M <br /> �� r <br />