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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F-F-0—F*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I OR - OIL? 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 <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 ej A. ilit? CENSUS TRACT <br /> Owner's Name Phone <br /> Address 4434 40 A/ City zr/y <br /> J� <br /> Contractor's Name .k"ILS ft) ZY 0sw License # /�'7AJ-Phone <br /> W�17 <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ —PUMP REPAIR M--Pump REPLACEMENT— /-7 <br /> Other /-7 <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 /> V 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 H.P. <br /> PUMP REPLACEMENT: State work Done <br /> PUMP UPAIR: LV State Work Done (9&4d ,or> .40 <br /> ,,DFqTRUCTION OF WELL: Well Diameter V V Approximate Df/pth <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 ow e an elief. <br /> t-40�SIGNED ITLE <br /> PLOPLAN ON REUERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IIZGROUT INSPECTION PHA sOPI-il")[NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS <br /> E H 1426 5/731M <br />