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A k <br /> f <br /> SAN JOAQUIN I OCAL VEALTH DISTRICT <br /> ICE USE: 1601 E. Aazeltor. Ave. , Stockton, Calif. ^,� • � � /� <br /> FOR OFF' r� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �V <br /> THIS PERMIT EXPIRES 1: YEAR FROM DATE ISSUED 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -� " � Y _ CENSUS TRACT S 4 7. ... <br /> 8 <br /> Owner's Name Phone ` <br /> Address '_ . l: 401G- t ..�� - - City <br /> Contractor's Name License 4J6�?„ ne . `� <br /> i <br /> n-TYPE OF WORK (Check): NEW WELL / / DEEPEN /-7- -RECONDITION -/-7 <br /> PUMP INSTALLATION _K1 PUMP REPAIR / / PUMP REPLACEMENT /—T <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT `BOTHER = . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of Well Excavation ly .10 <br /> Domestic/private Drilled Dia. of Well Casing 0 <br /> _ Domestic/public Driven Gauge of Casing d z <br /> Irrigation Gravel Pack Depth of Grout Seal 'S"a <br /> Other Rotary Type of Grout _ <br /> _ Other Other Information i <br /> 4 PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Desdribe 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 /> w after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> FWELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of y knowledge and belief. <br /> SIGNED /fit <br /> TITLE <br /> t -Xs (DRAWV PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I <br /> APPLICATION ACCEPTED BY .r _ DATE �� �,�' <br /> �, _ <br /> ADDITIONAL COMMENTS: <br /> PHASE. II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE .. �� ' � <br /> INSPECTION BY DATE j <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ?172 1M <br /> E H 1426 r..... <br />