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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r70f. OFIICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE -ISSUED Date Issued -1 <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 _j�Ajk, ,*,j fj EL&e'e- r"'ida uLbze CENSUS TRACT <br /> Owner's dame kaA7 $ Phone X99 '� 1i�17� <br /> Address )Vagi .J City CICO pft7 <br /> jr <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN RECONDITION RECONDITION_/_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /_ W REPAIR / / PUMP REPLACEMENT <br /> Other ./7 <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 /> 4 Domestic/public Driven Gauge•of Casing <br /> Irrigation Gravdi'Pack Depth of Grout Seal <br /> Other Rotary Type..of Grout <br /> Other Other Information <br /> ...._ <br /> 1. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT": State Work Done <br /> PUMP `REPAIR: / / State Work Done <br /> ,DFS RUCTION­ OF WELL. Wel-1 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 ot- .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 RtPORT 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 PLAT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION P I INAL INSPECTION <br /> INSPECTION BY DATE — INSPECTION BY t4je2tj DATE 2 .� <br /> CALL FOR--A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - <br /> E H 1426 5/731M - <br />