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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �"�" y'y- .2.6.5'Lr% <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7! <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/L0 ION-,�L�-eCQ ���j6=z�ENSUS TRACT <br /> Owner's Name _ Phone <br /> Address City la <br /> Contractor's Name License Phone34- <br /> -W <br /> 1 <br /> 4 7V <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_ RECONDITION /7 ESTRUCTION <br /> PUMP INSTALLATION / J PUMP REPAIR LS? PUMP REPLACEMENT /7 <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 0 <br /> Type of Pump H.P. -7 <br /> PUMP REPLACEMENT: J / State Work 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 Sari 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 i rue to the st 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 t. <br /> ADDITIONAL COMMENTS: gee <br /> A& -1i1 ts. <br /> PHASE II PROM INSPECTION r PHASE f II FINAL INSVECTION ' <br /> INSPECTION BY DATE INSPECTION BY �- Y `� DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.'?' '` , <br /> E H 1426 :�-2, G�tT , 'iLe , 1 <br /> /7 <br />