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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> !r fol.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 _ 5V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> j 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 .arid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - c-2 © fol CENSUS TRACT <br /> Owner's Name _ �;(�, Phone <br /> Address - City �C� 2J <br /> Contractor's Name fil2� � License kX,2�dlpPhone IY001;2� <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN '/—/ RECONDITION / / DESTRUCTION /_7 - - ` <br /> t <br /> PUMPIINSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT /7_ <br /> i 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 /> IndustrialCable Tool' Dia. of Well Excavation. <br /> Domestic/private Drilled Dia. of well. Casing `� V <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation r Gravel Pack DepESi cif Grout Seal <br /> Other _ �"" Rotary Type-.of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: -Contractor v <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: f Sate Work Done 1?�g7 )n <br /> R DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - _ Describe Material and Procedure .= G <br />? 1 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 'cn 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 blest of my knowledge and belief. 4 <br /> SIGNED TITLE <br /> i (DRAW PLOT PLAN ON REVERSE -SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -- - -- _._ <br /> APPLICATION ACCEPTED .BY DATE �) t <br /> ADDITIONAL COMMENTS: <br /> PHASE I GOT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /CJ 1 <br /> v CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H"1426 1 K/7g-im <br />