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ZSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70T.Z14FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7—IL_,f•_� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued yam-Jt� <br /> (Complete In Triplicate) 7Vn1: bf 5 -z2o _o/ <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 wade in compliance with San Joaquin <br /> County Ordinance No.--•1§ 2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address , <br /> City QP�VlLeai <br /> ` e <br /> i r+ License ��pZ- 4-1 �'1QIIE <br /> Contractor's Name <br /> TYPE OF WORK (Check): NEW WELLDEEPEN/l/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTXLATION / / PUMP REPAIR/ / . PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK.20p SEWER. LINES,;�� PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD42m/ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Ilia. of Well Excavation <br /> - Domestic/private Drilled Dia. of Well Casing Jr.' <br /> Domestic/Public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor o� <br /> Type of Pump H.P. - <br /> PUMP REPLACE11ENT: / / State Work Done <br /> PUMP 7tEPAIR: Sta-te_--Work:Done <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dist°i <br /> and the State of California pertaining to or regulating well ''construction. Within FIFTEEN11 DR <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <br /> WELL DRILLERS REPORT of .the well and notify thein before putting the well in use. The above <br /> information is true to the est of my knowledge- and belief. <br /> CSIGNEDLK TITLE , <br /> ADRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE I <br /> i <br /> APPLICATION ACCEPTED .BY DATE4 � - -- <br /> ADDITIONAL COMMENTS: <br /> PHAS..9 gi GROUT INSPEC ION PHASE III/FINAL INSPECTION <br /> ' `2- <br /> INSPECTION BY DA7E <br /> INSPECTION BY DAT`E�T `2-'1 <br /> CALL FORA GROU C I�PRIOR GROUTING AND FINAL INSPECTION. I1�`� <br /> 7 u 42fi 5/731M <br />