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w <br /> D SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ft+7F. OITICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1--F- <br /> THIS <br /> 3THIS 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 V)A-fj Scoli .4`` It .Pp o& A.I./ f /1-rdMY CENSUS TRACT -_ <br /> Owner's Name _ � 1 Phone <br /> Address _ Do 14 V-,v? r o4"Md City <br /> Contractor's Name '�' atti License # jj �1v Phone i L X676 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN/ / RECONDITION /-T DESTRUCTION /-7 <br /> PUMP INSTALLATION / MP/ PUREPAIR / / PUMP REPLACEMENT /=T <br /> AL <br /> Other <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 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigati.on Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout io <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor At, <br /> Type of Pump A.P. 3G <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP UPAIR: A S tate Work Done ,V19`.0 e o )1 0 Jy Id-All A4Vl <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 Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informatioq is true to the best y knowledge nd belief. <br /> SIGNED �'i'/lr <br /> TLE <br /> DRAW PLOT PLAN ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ' PUiASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I ' FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY I DATE 7-a <br /> CALL-- -ICOR A,GROUT -INSPECTION PRIOR. <br /> .TO GROUTING AND FINAL INSPECTION. <br /> 5173WE tt 1426 � j <br />