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.SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f-POT:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7U- u k�) <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S•20',7q <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. 1$52 and the Rules and Regulations-of the San Joaquin Local Health Disrri.ct. <br /> JOB ADDRESS/LOCATION j^jPr eVG 1I; a�f�TrENSUS TRACT <br /> Owner's NamePhone <br /> Address Z2221 _ 120 City Pt 401 <br /> Contractor's Name License # D Phone <br /> a5700 dao <br /> TYPE OF WORK (Check) : NEW WELL _1�;K DEEPEN '/ { RECONDITION / { DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR '/ / PUMP REPLACEMENT /-7 �1 <br /> Other / / (� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � . <br /> �( SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 1 OTHER C <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 W } <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> - Other, Other Information Q -,6q 0-yarl" <br /> � i <br /> PUMP INSTALLATION: Contractor i <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: L <br /> 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 Health District a <br /> WELL DRILLERS REPORT sof 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 /> L <br /> SIGNED TITLE <br /> W PLOT PLAN ON R RSE SIDE) (y <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE : ��� <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHA5E,II1/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _. DATE '7f/ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />