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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ;Stockton, Calif. <br /> TelephonQ: <br /> APPLICATION FOR WELL CONSTRUCTION".OR PUMP PERMIT Permit No. , 0 <br /> THIS PERMIT;sEPIRE5;1=Y.EAR 0RJI, :DATE ISSUED `Date Issued <br /> ., <br /> 4 ,;j <br /> .{Cbm}ilete Iti TY•iplcate) <br /> Applicatiotitsis;..hereby-.madeito the fSangJoaquin,Local. Hdalth• D1:strict<for!'a permit, to construct <br /> and/or install the work herein described. This_appl:i:cationvis-. made:in ,compliance with'San-Joaquin <br /> ="County°:0rdinaiicefNo-(1862 aand•,�thd--Rales"°andr-,Regulations �6f-the,San Joaquin--Lo cal-Health District:`- � <br /> aW <br /> JOB ADDRESS/LOCATION 7� ccs • "'' CENSTI S TRACT <br /> .. ,.VJ -t�`.9.'�. ��'.,a Fr..j.S 3. .,f � -� y,t� .»"� i3r say ' Lti � i iJ.!. -. ' w. , ' - . : - .•. <br /> Owner`s^Namd7 ._Phone: <br /> r <br /> Address l 0'W oo __ O u a City <br /> Contractor's NameY e h;O eh _ License U8JI U-Phone ' <br /> TYPE OF WORK (Check) : NEW WELL'/DEEPEN / / RECONDITION / / DESTRUCTION <br />` . PUMP INSTALLATION / / PUMP REPAIR/ / ' PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC.TANK Q SEWER LINES PIT PRIVY p <br /> SEWAGE DISPOSAL .FIELD CESSPOOL/SEEPAGE PIT . OTHER <br /> t <br />' INTENDED USE "TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial_ Cable Tool. Dia. of Well Excavation /Z <br /> v/: Domestic/private' Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack .Depth. of Grout Seal as necrsso!v <br /> Other _ Rotary Type of Grout �f <br /> . . . Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of,.Pump H.P. <br /> PUMP REPLACEMENT: / '/`''State Work: Done <br /> PUMP REPAIR: / / V State Work Done } <br /> DESTRUCTION 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 Focal Health District <br /> I ' and :the State- of California pertaining to or regulating well construction. Within FIFTEEN -DAYS <br /> afte;x completion' of my work on a new well; I will furnish -the San. Joaquin Local Health`District a <br /> I 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 /> SIGNED �� _. _ TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> +` FOR DEPAR MENT USE ONLY <br /> PHASE I <br /> -APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE' INSPECTION BY DATE ?— <br /> ' C�ALL�FOR A GROUP INSPECT ON PRIOR. TO„GR i3T G AND FINAL INSPECTION. <br /> E H 1426 , - G*�, l ._. 4 ,, <br />