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7 vn.claL� SAN JOAQUIn LOCriL 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. 9.3._5-6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1,,�_.2_ 3 <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 District. <br /> JOB ADDRESS/LOCATION &&A <br /> L CENSUS TRACT <br /> Owner's Name C . G _ Phone <br /> Address !J ! /��� City 8� <br /> Contractor's Name License # Phone 3 -�3 -3 <br /> TYPE OF WORK (Check) : NEW WELL~DEEPEN /_� RECONDITION /_/ DESTRUCTION /_7PUMP INSTALLATION, PUMP REPAIR / / PUMP REPLACEMENT /_T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKm SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A-.--Cable Tool Dia. of Well Excavation <br /> -- <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /Q r <br /> i_,- Irrigation gravel Pack Depth of Grout Seal C, <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 HAYS <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 .Z-114eT— TITLE �/ <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY l�r/f?� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE_ III/FINAL INSPECTION <br /> INSPECTION BY DATE � _ <br /> � INSPECTION BY� ,� DATE � <br /> - l _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 2 N 1426 7172 114 <br />