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'41 - / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. 01Fj ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR. WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Hereby rade 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 ano the Rules and Regulations <br /> , 'of, /the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION � � �`-' � -`�-� CENSUS TRACT <br /> Owner's Name /—Z::�/ Ute/ 7�1 Phoneq�f,�?- � <br /> Address 9� City - <br /> Contractor's Name / ��/ / V License �vD''-Z>73Phone,4 7 6 9"X� <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN I I RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / ( PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: i / State Work Done h <br /> PUMP 'tEPAIR: / / State Work Done <br /> DF-TRUCTION 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 <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED e&L—A, - fu, / � �.� mss. 1� - TITLE <br /> �T (DRAW MOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PURSE I <br /> APPLICATION ACCEPTED .BY DATE 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE JJIJFINATINSPECTION <br /> INSPECTION BY DATE INSPE N Bj( 47L. 77? <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE TION. <br /> E H 1426 5/731M <br />