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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ic3 . Oi1ICE USE: 7 / 1601 E. Hazelton Ave., Stockton, Calif. <br /> r- v Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76- a$6 p <br /> t THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application idereby 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 / ( CENSUS TRACT <br /> Owner's Name Bal Phone <br /> Address <br /> Contractor's Name icense #/Z�Vhon�Z <br /> TYPE OF WORK (Check) NEW WELL / DEEPEN /_7 RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION 0 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / 1 <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 4.► <br /> Domestic/public Driven Gauge of Casing <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 <br /> PUMP UPAIR: / / 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 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 C-etit 6�20 TITLE 4n A4�� <br /> (DRAW PLOT PLAN ON REVERSE SIDtY <br /> FOR DEPARTMENT USE ONLY <br /> PdASE I <br /> APPLICATION ACCEPTED BY DATE 3 /2 <br /> ADDITIONAL COMMENTS: <br /> PIIAS I GRO T INSPECTION PHASE III/ INAL NSPECTION <br /> INSPECTION BY <br /> DATES - 7 I INSPECTION BY TE — .3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />