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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '1 3- i]-i W , <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 i <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the RulesandRegulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION sz CENSUS TRACT y <br /> Owner i s Name <br /> 12� fJX�- ® Phone <br /> Address /.t1 (�;r/ ---- -- City <br /> Contractor's Name License VS_ Phone ��`5��}� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /7 DESTRUCTION I-7 <br /> PUMP INSTAL TION / / UMP RE .AIR / / PUMP REPLACEMENT /_7 � <br /> Other _/_7 =&_ <br /> L,) i4 a' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C <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 0 <br /> Irrigation Gravel Pack Depth of. Grout Seal, 6 O <br /> Other Rotary Type of Grout <br /> Other Other Information <br />` PUMP INSTALLATION: Contractor .�z� <br /> Type of Pump H.P. l <br /> PUMP REPLACEMENT: / / State Worts Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -7 <br /> APPLICATION <br /> DATE <br /> APPLICATION ACCEPTED BY /� „� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> :INSPECTION BY DATE !e+Eg'2INSPECTION BY -_- DATE �' <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. ` <br /> 2 1M <br /> E H 1426 7/7 <br />