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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ror. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. , <br /> fc> Telephone: (209) 466-6781 j <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z5z:. J <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued a _$-7th � <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 /> JOB ADDRESS/LOCATION �' �' IV% � """` . CENSUS TRACT <br /> Owner's Name _ �Ae�-.- ZW d/_Lt_� ---_-_-- -- Phone <br /> Address City <br /> Contractor 's Name. <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL /{ DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAI / / PUMP REP EMEN /-7 <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPMiYSS'tt-kAGE 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 <br /> f <br /> PUMP REPLACEMENT: { / State Work Done <br /> 4 <br /> k� PUMP UPAIR: / State- Work Done <br /> DFSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r' Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />'I 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 TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SI E <br />' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I_. r p <br /> APPLICATION ,ACCEPTED BY - cJ, DATE a 0 <br /> ADDITIONAL C01,01ENTS: }' <br /> ,`. PHASE II GROUT INSPECTION P%3t/ITafitINAL INSPECTION <br /> INSPECTIONBY « DATE INSPEC O DATE <br /> CALL FOR A GROUT INSPECTI'& PRIOR TO GROUTING AND FINAL INSPECTION. <br />