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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,;P-/%3 4.) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z2Y2�y <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 1 <br /> County Ordinance No. 1862 and the Rules and Re ulations of the Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION nG CENSUS TRACT <br /> Owner's NamePhone <br /> � Z4,0 � <br /> 0 <br /> Address City � _ h <br /> Contractor's Name c K <br /> / /T/��'t1_�I ....__ License jj g&9-,7d3 one ��.K <br /> a <br /> TYPE OF WORK (Check) : NEW WELL /P'DEEPEN '/ / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / f PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE 0 . 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 o0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ` s <br /> Other Other Information t1 <br /> t <br /> PUMP INSTALLATION: Contractor `�V <br /> Type of Pump „ _ . H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .pESTRUCTION 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 Al knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 4J,6c DATE `a -lZ 7-Z— <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A G OU INS TION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> y�E H 1426 � � 7 1M <br /> ;'/!/t ./�,-�a b� .Gtr - ��� c�%� �d c -�•� CO <br />