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'M V' SAN JOAQUIN LOCAL HEALTH DISTRICT ^� E t <br /> F"d-r-OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. / <br /> Telephone: (209) 466-6781 <br /> ~` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�7S- 3�L� <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 S' 2 J�2/ CENSUS TRACT <br /> Owner's Name _ ?IVaee <br /> Phone qA C 3/X <br /> Address 3 - �' / �� City ��'``�` <br /> Contractor s Name , <br /> License 2-65 76/ Phone 4eG St fr 3 <br /> TYPE OF WORK (Check): NEW WELL / I DEEPEN/ / RECONDITION /-7 DESTRUCTION /-T'y� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT �, <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 61) <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 /> PUrR' INSTALLATION: Contractor r J <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DFgTRUCTION 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 ,2L�gd�11r��� �s�2 �.�'TITLE _ <br /> OF (DRAW9PLOT PLAlwrdiv REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - - DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5 �3ll� <br />