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F, SAN JOAQUIN LOCAL 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.?.3-3 .Z1�_) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued3 <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 /L � �. /�) /�//' __-- CENSUS TRACT <br /> Owner's Name j " �',' %.�)X11 j� ,(��,�j/L-_ Phone - <br /> Address / f l '.- f � �; f.- r `� .. )�-Cityi <br /> L <br /> Contractor's Name _LLi/," 4 l+VLI l Lf(<� %, % l' l x License # � Phone <br /> TYPE OF WORK (Check): NEW WELL <br /> 5�.' DEEPEN /_7 RECONDITION /__7 DESTRUCTION /7 <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 6� <br /> _ w <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation f�« <br /> — , Domestic/private Drilled Dia. of Well Casing . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal f <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> F L T l lry ff } <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 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 /> r <br /> � 1 <br /> SIGNE --- r^ c: < ,,;.c` .f:-� TITLE <br /> -_ -� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: r <br /> PHASE II T 0 PHASE III INAL INSPECTION <br /> INSPECTION BY 16ATt INSPECTION BY , + DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 '� '2 im <br />