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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£.*01'1I SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,,, 3� <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 con:atruct <br /> and/or install the work herein described. - This application is made in compliance with San Joaquit <br /> County Ordinance-.No. 1862 and the Rules and Regulations ,o£ the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,Ar G e � �L . `W' ` �a� CENSUS TRACT <br /> A <br /> n - <br /> Owner's Name Phone�. �- - - ------� <br /> Address w - - .: -� - City ' - - <br /> F Contractor's Name +--. License # Phone -� <br /> - <br /> TYPVOF' WORK�(Check): 'NEW WELL'/Y� 'DERPEN_/ f- RECONDITION / / DESTRUCTION /� op <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_77 <br /> Other -f-7 C Le s7rAq,6w-' <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 <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. 0 <br /> PUMP REPLACEMENT: / / State Work Done <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 we-1-j,_I. will furnish the San Joaquin Local Health District f <br /> r; WELL DRILLERS REPORT 'of .tlie well and notify them before putting the well in use. The above <br /> i; <br /> 1 information is true to the bestof my. knowledge and belief. <br /> Ii SIGNED <br /> TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> r P11ASE I <br /> APPLICATION ACCEPTED .BYE DATE <br /> ADDITIONAL COM1,1ENTS: Pi�ASE III/FINAL INSPECTION ' <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 5v—.7 XY <br /> CALL FOR A=GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> _ 5/731M <br />