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IN <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F07FOFFICL USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 s- w> <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3"/)-- 7S <br /> (Complete In Triplicate) 1Q�°,✓ <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 an Regulations of the San Joaquin Local Health district. {� <br /> JOB ADDRESS/LOCATION 6 CENSUS TRACT <br /> Owner's Name ' f C 41 Phone <br /> Address City <br /> Contractor's Name r License #12_&&3 Phone <br /> _ 1 <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN '/ / RECONDITION / ( DESTRUCTION /_7 <br /> PUMP INSTALLATION / f PUMP REPAIR / / ' PUMP REPLACEMENT 17 <br /> Other /_7 I <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANKQ- SEWER LINES PIT PRIVY C <br /> SEWAGE DISPOSAL FIELD D CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _P <br /> Domestic/private Drilled Dia. of Well Casing f <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 Cfir <br /> * .406 J <br /> Type of Pump 4 Asap LauaL -- --- - H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP 'tEPAIR: /7 State Work Done <br /> f� <br /> .DFGTRUCTION OF WELL: Well Diameter Cy Approximate Depth <br /> Describe Material and Procedure <br /> i. <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> d the State bf 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 /> informati <br /> juery <br /> best mk o le e a d belief. <br /> SIGNED �. r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Z .✓L DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P AL INSPECTION 12 <br /> INSPECTION BY DATE "p` INSPECTION $Y DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI N. <br /> E H 1426 5/731M <br />