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SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> EOF. OFFICE_ USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,��� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued A— <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 At, /�r�. @ �✓ CENSUS TRACT <br /> TV <br /> r--� <br /> Owner's Name a_ Phone J <br /> Address City osD�L <br /> Contractor's Name ' License # 123A) Phone4-j, <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN '/-7 RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR � PUMP REPLACEMENT — <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 /> _ - 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 H.P. <br /> 44 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: / State Work Done bAd buW Z-0 .4e Z—7L— --- <br /> WNTRUCTION 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 kno a and belief. <br /> ro ' <br /> SIGNEDLw- -I.. S4AX <br /> TITLE <br /> DRA PLOT PIAN ON VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> P11ASE I d <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE A,,gOUT INSPECTION PHASE II;/FINAL IN5N <br /> INSPECTION BY DATE INSPECTION BY L DAT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND .FINAL INSPE ION. <br /> 14 ;731M G F—�> <br />