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�(Q SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOf.;01 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.. f <br /> Telephone: (.209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT . Permit No. P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7- - 7 <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 stealth District. <br /> JOB ADDRESS/LOCATION -6 IF. cle l,,:ch ---- CENSUS TRACT <br /> Owner's Name z& r Phone <br /> Addresszqz <br /> rJ City •� <br /> ' License # ,f Phone G 3 <br /> j <br /> Contractor's Name ); �� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN I / RECONDITION_/ / DESTRUCTION J_ <br /> PUMP INSTALLATION f_1 PUMP REPAIR / / PUMP REPLACEMENT 1 ` <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK r vP- SEWER LINES PIT PRIVY i <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 1 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 /> f �.Other— _—A-1 Rotary Type of Grout ' <br /> Other- Other Information <br /> PUMP INST-ALLATIDN: Contractor <br /> -' Type of Pump H-:P. <br /> 1 -`A <br /> PUMI? REPLACEMENT: State Work Done <br /> PUMP UPAIR: / / State,Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Desdribe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sar. Joaquin Local Health District <br /> 3 and the State of California pertain-ing to or regulating well 'construction. Within FIFTEEN DAYS <br /> ;after completion of my work on a neta well, Im will furnish the mSan Joaquin Local- Health District a <br /> WELL DRILLERS REP of the well and notify them before putting the .well in use. The above <br /> information is ue to the best of my knowledge and belief. <br /> SIGNED '� ;� TITLE <br /> (DRAW ZIT PLAN ON REVERSE SI E) ! <br /> FOR DEPARTMENT USE ONLY <br /> k PHASE I 7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PI SE-IZ GROUT INSPECTION P TI E III/ IN INSPECN <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> CALL FOR R INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E ---- - 5_/,731M <br /> H 1426 ��- <br />