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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �F.- O C <br /> ',US 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z - <br /> "0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedcf <br /> (Complete In Triplicate) <br /> Application is Fdreby 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 theRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION D9 t714Z CENSUS TRACT <br /> Owner's Name 0�15 SL o4-0 /1/ o Phone��� �_7 <br /> Address 4e- � /)e-fae&7- � City <br /> Contractor's Name ¢—z T/"� G/ License , (9__ Phone4eb ���'X' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN J / RECONDITION / - <br /> _/ DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR Y7/—PUMP REPLACEMENT /—T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TA4K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <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 /> Domestic/public Driven Gauge of Casing <br /> I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done I <br /> PUMP UPAIR: / / State Work Done <br /> .DF'RTRUCTION 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 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 a�...1r 1rn �., _. TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PUASE I �7 n(�� <br /> APPLICATION ACCEPTED BY s !�.�-- DATE fI' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASB III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ^r,.�— DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 11 1426 5/731M <br />