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G <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFjTr**OFr10E USE: l� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r _ ?6-.306P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> s <br /> JOB ADDRESS/LOCA ON / J , CENSUS TRACT <br /> %1 <br /> Owner's Name Phone <br /> Address ° ! �' �s Lt'�iC,'City <br /> Contractor's Name E. ^1.. • License 'Phong _fz <br /> TYPE OF WORK (Check): NEW WELL ,JV DEEPEN j-7 RECONDITION / / DESTRUCTION f7 <br /> PUMP INSTALLATION KI PUMP REPAIR / j PUMP REPLACEMENT /-7 <br /> 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 /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private 'Drilled Dia. of Well Casing <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: j j State Work Done <br /> PUMP 'tEPAIR: / / 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 Hearth 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 TITLE ))l0./� <br />' DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> E PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 1-17 <br /> PHASE I GROUT INSPECTION PHA&ZZOI INSPECT <br /> INSPECTION BY DATE '-71 INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIG�2 +T0 GROUTING AND FINAL CTION. <br /> E H 1426 5/731M <br />