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SAN"JOAQUIN LOCAL HEALTH DISTRICT <br /> . OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - to <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -13 <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 QCjg S�#W# *-rSawi-A 47nj )1#10LOht CrCCV6 CENSUS TRACT <br /> PTO"Itft" <br /> Owner's Name A 24a Phone <br /> Address d- bad uj t A'� City _S22 Lto aC7Y/3-•.� <br /> c <br /> Contractor's Name License #/J:�hone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Exca-Mtion <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 44 H.P. <br /> 4 <br /> V <br /> PUMP REPLACEMENT: State Work Done <br /> 4g=we--all <br /> State Work Done J�t iln A/jt,.j <br /> lv o <br /> V <br /> ,,DF'-TRUCTION 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 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 9.f ,;7 "owledge Apd belief. <br /> SIGN AP <br /> a TLE <br /> FLOT <br /> M PLAN rN 744FIVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS& III/F-INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /4. 74 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. CD <br /> E H 1426 5/731M - I <br />