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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 5--jr-.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z, 4) <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 /> -A ZLI. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> 4z <br /> Address City -al I L FLAZA <br /> Contractor's Name License # &�6 Pkone <br /> TYPE OF WORK (Check): NEW WELL /Z �DEEPEN RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/—PUMP REPAIR /—/—pump REPLACEMENT /7 <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK >?ool SEWER LINES PIT PRIVY <br /> XSEWAGE 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 At ayq <br /> V Irrigation L,- Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information j:�7-K7-A4 ,—wxe4- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP UPAIR: State Work Done <br /> 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 RE-PORT of the well and notify them before putting the well in use. The above <br /> informatowis tru to the berj,�Ay kn le and belief. <br /> 6 <br /> SIGNED TITLE, <br /> DPLOT PLAN ON REVERSE SIDET�4 <br /> F0F,,PF,#ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP 1-4 IV)IA DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECT ON PIIJZWNAL INSPECTION <br /> INSPECTION BY DATE IA—Z3 INSPECTIDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> EH 1426 5/731M <br />