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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F.- }:ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <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 /> ?-....::� Z'up-- bytes!? <br /> JOB ADDRESS/LOCAT :._IONt""` �� – CENSUS TRACT <br /> W _... s...,.._�; <br /> Owner's Namef� . 0 /IY[_�G�l - - - Phone – <br /> Address 0 City <br /> Contractor's NameLicense # Phone <br /> TYPE OF WORK (Check) : NEW WELL . DEEPEN / / RECQNDITION f-1 DESTRUCTION /? <br /> PUMP INSTALLATION / j PUMP REPAIR /-7 PUMP REPLACEMENT /- <br /> Other 1-7 <br /> / N <br /> DISTANCE TO NEAREST: SEPTIC TA14K ;2O6 SEWER LINES /00 PIT PRIVY :11,4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERcD `frJ1�G <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool' Dia. of Well Excavation <br /> _Y Domestic/private Drilled Dia. of Well Casing � �j-yXp – – <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ��`a e - <br /> Other /� Rotary Types 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 `2EPAIR: / / 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 /> i SIGNEDTITLE <br /> (DW4 PLOT PLAN ON RESE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED .BY DATE !Z:nL,�9_75l <br /> ADDITIONAL COMMENTS: - <br /> PHAS . I�2OUT INSPECTION PHA II/FINAL INSPECTION <br /> INSPECTION BY DATE " INSPECTION B DATE /D:2/-7 / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> /7 SIV <br />