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Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For.-OST E USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 /> axed/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 , CENSUS TRACT <br /> Owner's Name �a,)W&x - Phone <br /> Address 10 7 City , C540 -- . <br /> Contractor's Name License # j4 Phone <br /> TYPE OF WORK (Check): NEW WELL /! EEPEN '/ / RECONDITION I I DESTRUCTION 1-7 <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 N14 <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 t� <br /> t Other Other Information ' <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Puiip-- ZL P. <br /> PUMP REPLACEMENT: / State [fork Done 2.0,b U W- ! & _ e` <br /> PUMP "REPAIR: 17 State Work Done <br /> c Approximate Depth <br /> ,DF'- TRUCTION OF WELL: Well Diameter APP <br /> Describe Material and Procedure _ <br /> I hereby agree to comply with all laws and regulations of' the Sari 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 /> CELL DRILLERS REPORT of .the well. and notify t e o utting the well in use. The above <br /> information is true to the best of my wle and heli f. _ <br /> SIGNEIR � Aj - <br /> LE <br /> (D T PL N RE SE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE " <br /> ADDITIONAL COMMENTS: <br /> PHASE II QROUT INSPECTION PHA$ 1 FItjAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 60 <br /> CALL,FOR A GROUT INSPECTION PRIOR TO GROUTING, AND FINAL INSPECT N. <br /> 5/.731M <br />