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~/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7_=1OF.-O FICE USL: 1601 E. Hazelton Ave. , Stockton, Calif., <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Vit/-5S'1/rE) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //- i -7th <br /> (Complete In Triplicate) <br /> Anplication is here y 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 a?M era f the San Joaquin Local flo: l.th District. <br /> JOB ADDRESS/LOCATION ejrCE SUS TRACT <br /> ✓C�' 0> <br /> � `rte/ <br /> Owner's Name Phone yc. <br /> AddressIPA4�JR A Cit}�� � / <br /> Contractor's Name License #c _17_ Phone% <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN %/ RECONDITION / j DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TA K SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �} <br /> TNTENDI D USE TYPE OF W LL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> + <br /> tic/private Drilled Dia. of Well Casing <br /> Domestic/public _ Driven Gauge of Casing / <br /> � _,,PrT71-gation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ; } <br /> Other Other Information <br /> PUSH' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACErENT: j j State Work Done <br /> PUMP 'ZEPAIR: / j State Work Done <br /> 14 <br /> `1 <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 Sate 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 /> WE'LL DRILLERS REPORT of the well gnd notify them before putting the we in use. The above <br /> information i true to he be t m knowledge and belief. <br /> a <br /> SIGNED TITLE <br /> DRAW T PLAN ON REVERSE SI <br /> OR DEPARTMENT USE ONLY <br /> PiASE I ` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COM1,1ENTS: <br /> P`tu�SE II GROUT INSPECTI N PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL kOR A GROUT INSPECTION PRIG: Td GROUTING AND FINAL INSPECTION. <br /> a 1426 51 1M <br />