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y r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT < <br /> Fr--OF. OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> F— APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Perfit bio.. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �- 7�7U <br /> (Complete In Triplicate) <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. 1862 and the Rules and Regulations of the San Joaquin Local Health Dia�rict. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �ev i//e+S Phone <br /> Address . .G !. '�;.a-r '�.�l.P City r'- <br /> Contractor's <br /> Contractor's Name i ^^eL�t�'l� License25- Phoned. <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN '/ / RECONDITION /7 DESTRUCTION /? <br /> PUMP INSTALLATION ''-PUMP REPAIR /`7 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 ' <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 S��nl. ._.._ A.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,,UFgTRUCTION 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 wel.l '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 bes of my knowledge and belief. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: /17 <br /> PHASE II GROUT INSPE&TION PHASE IIi NAL uspEttiov <br /> INSPECTION BY DATE INSPECTION BY, 7� <br /> .._ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E R 1426_.: 5/731M <br />