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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R-0 .,:'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 �j_ locJ3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;7 fA Gc� <br /> f <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. 18�'and the Rules and Regulations of the San Joaquin Local Health District. <br /> . JOB ADDRESS/LOCATION Q'-) tS � ,S'cx46ri CENSUS TRACT <br /> Oimer'sName <br /> �� . <br /> Phone <br /> Address '4 �dl/I�i�. City , .3.� C d- <br /> Contractor's Name License # / 4 'e. Phone -7 ILL/ 5_L <br /> TYPE OF WORK' (Check) : NEW WELL DEEPEN/_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / (/ PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 <br /> e -- <br /> DISTANCE TO NEAREST: SEPTIC TANK p, SEWER LINES PIT PRIVY <br />'7 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> INTENDED USE. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia. of Well Excavation i6l, <br /> Domestic/private ,a - Drilled Dia. of Well Casing, 6. <br /> Domestic/public Driven' Gauge of Casing z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> -- Other Rotary Type of' Grout <br /> Other Other. Information44 y,� .4� <br /> PLT RT INSTALLATION: Contractor. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: <br /> / / State Work Done' <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 ori a new well., I will furnish the San Joaqdin 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 knowledge and belief." <br /> SIGNEDTLE <br /> (DRAW PLAT PL N REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY p,.n, 13 <br /> W J�ycL(,,ES�, p�--r9'�"''" ! � <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS IIT/ INAL INSPECTION <br /> INSPECTION BY DATE R - INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. `y"`b' <br /> E H1426 n <br />