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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOF. OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> t-" Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zs-�241 <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 / i CENSUS TRACT <br /> Owner's Name 1 J'' Phone *, <br /> Address t/, f city A.- <br /> Contractor's Name /- k;e r`r} � • License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN RECONDITION/-7 DESTRUCTION <br /> PUMP INSTLATION PUMP REPAID / / PUMP REPLACEMENT j�T <br /> AL <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> W <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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: j / 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 Heal h District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. ThO above <br /> information is true to the best of my knowledge and belief. <br /> r <br /> r TITLESIGNED , , RAW <br /> -. <br /> PLOT PLAN ON REVERSE SIDE} <br /> !' �Q F R DEPART10= USE ONLY s <br /> PHASE Iio Z��f*#V 50" Q <br /> APPLICATION ACCEPTED BY DATE U <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 731M <br />