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V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> '0'f. OFFICE 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 3- <br /> (Complete In Triplicate) zbr- tic -O2- <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> c-�' +� CENSUS TRACT <br /> Owner's Name R Phone <br /> Address f.C-11V City <br /> Contractor s Name License # %j271, --Phone l 271. <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / PLW REPAIR // -/—PUMP REPLACEMENT /-7 {�1 <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I`f� <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 �7 <br /> 1 <br /> Type of Pumptti H.P. - �'O <br /> F _ <br /> IE PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'zEPAIR: /X/ State Work Done k m <br /> DFRTRUCTION 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 /> 5 <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 no edge andt elief. <br /> SIGNED2%0--Z <br /> \ ITLEs f" . <br /> D W PLOT PLAN ON RSE SIDE)�� <br /> i FOR DEPARTMENT USE ONLY <br /> r PUASE I <br /> APPLICATION ACCEPTED BY AV DATE <br /> ADDITIONAL CO,INkIENTS: <br /> PHASE II GROUT INSPECTION PHASE /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5 , 73IM <br />