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w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> , :. OV 1'10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .1 �0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-.:4/ -7G <br /> (Complete In Triplicate) <br /> Application is hereby .jade to the San Joaquin Local Health District for a permit to constr.+.ar.t <br /> nd/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 CENSUS TRACT <br /> Owner's NamePhone <br /> Address Z& rov xe � _ i" City 7 <br /> Contractor's Name , /�c `, �`G, License #�� �' Phone -� -/T <br /> TYPE OF WO1a (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /-7 <br /> PJ1,T INSTALLATION j / PUMP REPAIR / j PUMP REPLACEMFi4T-- _/ff <br /> Ocher / j <br /> DISTANCE TO NEAREST: �SL;P'iIC T! d _ 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 tl <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: Co-atractor � <br /> Type of Pump S- H.P. l <br /> 2U-Nal' REPLACE MNT: ! State Work Done J-,J , +r.jp_ L?AV ra,�,0;�.-f' : ;ld-lA ®P, <br /> PUMP `iFPAIR: State Work Done <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 a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS R PORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED , �44 TITLE !i <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> Pli SE I <br /> APi LICATION ACC. PTSD BY �_ DATE <br /> ADDITIONAL CO,% 1ENTS: <br /> PRASE II ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,21 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E -H 1426 5/731M <br />