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w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF..O.FFICE .USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. G l/ <br /> THIS PERMIT EXPIRES 1 YEAR .FROM DATE 'ISSUED 17- 717/° <br /> 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,-a. d� he R s ay , Regulations of the San Joaquin Local Health District. <br /> 01 <br /> r W cart/ 4/4-1=} flY <br /> JOB ADDRESS[LOCATIONY. <br /> / U /YliAef CENSUS TRACT <br /> Owner's Name ,L �' Phone W 3 6 c?5— <br /> Address L0 0 1 p� ' <br /> City <br /> Contractor's Name g S ,r License #I0.5-3?.Phone 9V2-3 el 4 <br /> TYPE OF WORK (Check) NEW KDEEPENRECONDITIONTION /_7 DESTRUCTION % f <br /> PUMP INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT 17 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK 12,0 SEWER LINES !`5�� PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER + <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial /fable Tool Dia. of Well Excavation <br /> _ -Domestic/private Drilled Dia. of Well Casinglo <br /> Domestic/public Driven Gauge of Casing 12 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout p <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S H.P. <br /> PUMP REPLACEMENT: J J State Work Done <br /> PUMP 2EPAIR: J J State Work Done <br /> ,DESTRUCTION 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-1 <br /> WELL DRILLERS REPORT pfthe well and notify them before putting the well in use. The above <br /> informat" n true o th best of my kriowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PRASE I <br /> FOR DEPARTMENT USE ONLY <br /> : <br /> APPLICATION ACCEPTED .BY "V V DATE 12-/01`23 ' <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GRFOUT INSPECTION PHASE II AL SPECTION <br /> INSPECTION BY DATE :INSPECTION BY E <br /> - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> -- EH 1426 <br />