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-SAN JOAQUIN LOCAL HEALTH DISTRICT <br />-Fla—r.-OFFICE 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 2z <br /> (Complete In '.triplicate) <br /> application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 111d/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 />'OB ADDRESS/LOCATION <br /> 5", 0Ir !� CENSUS TRACT %. <br /> wwner's Name d, V -e r F, <br /> r+ „_,. .... ,.. Phone 41« D 0 <br /> address J ''Yr e-. ) City <br /> lontractor'a Name QL+J Y7 p:r ` <br /> License # Phone <br /> C <br /> TPE OF WORK (Check) : NEW WELLI / / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUW REPAIR / / PUMP REPLACEMENT /-7 y <br /> Other ./ / <br /> IISTANCE TO NEAREST: SEPTIC TALK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial + <br /> Cable Tool Dia. of Well Excavation <br />_Domestic/private Drilled Dia, of Well Casing L� <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation .1 Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> I Other Other Information <br />'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: <br /> / / State Work Done <br /> ZE <br />'UMP PAIR: State Work Done <br /> � � � <br /> /. / 99 <br /> IFgTRUCTION OF WELL: Well Diameter Ap roximate Depth 3s <br /> Describes Material and Procedureirr�r�.ti, <br /> 1 <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District !: <br /> Lnd the State of California pertdining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 1ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above } <br /> nformation i .-t,a to the best o�y knowledge and belief. <br /> iIGNED 7 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />(RASE I <br /> XPLICATION ACCEPTED BYDATE <br /> l ( / s <br /> ADDITIONAL CO;u41E-NTS: . . <br /> PHASE II GROUT INSP9CTION PHASE I1/FINAL INSPECTIO <br /> INSPECTION BY DATE + INSPECTION BY DATE o`RS� is <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTT . � <br />