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kloo#kli JOAQUIN LOCAL IEALTH DISTRICT <br /> FOR 0 1601 E. Hazelton Ave., Stockton, Calif. <br /> IAT Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,F/&RAd <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 oftheSan Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A57ZALJ& . Q-( .-�A/ AVe- CENSUS TRACT <br /> Owner's Name iQ /,P�T7 J Phone le <br /> Address City <br /> Contractor's Name �sT��R � �)TE�/f��T� License # 123�Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION J / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / / <br /> "DISTANCE TO NEAREST: SEPTIC TANK/V 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 Excavation116 <br /> Domestic/private Drilled Dia. of Well Casing 6 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout OFV <br /> Other Other Information <br /> 'PUMP INSTALLATION: Contractor - -At— <br /> Type of Pump 77,&eR1AJ& H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .pESTRUCTION 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 cot <br /> of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRORT of thew 1 and notify them before putting the well in use. The above <br /> infor uet the b t of my knowledge and belief. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY „ ,. .,. y' DATES 7 7 <br /> ADDITIONAL COMMENTS: <br /> r PHASE II GROUT INSPECTION PHARV II INAL INSPECTI <br /> INSPECTION BYVr T- DATE INSPECTION BY DATE <br /> • CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSICTION. <br /> E H 1426 �110�- <br /> 7jrm4/7 1M <br />