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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL;OFi<ICE USE: 3 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6782 <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 thejSan Joaquin Local: Health Dis�ric�. <br /> { cc�t= -Peltier. Rdr �•G::?�% EaSV Or 6-441077- �f 7- 22a�o y <br /> JOB ADDRESS/LOCATION 6,90" SocrA of &I-he-r CENSUS TRACTS 4 7 <br /> I <br /> !" <br /> Owner's Name �oa(3 .t1 S I f_A/�i! Phone -727 a�7� <br /> Address F4D-50y city. <br /> Contractor's Name b0/4j 6; S ®Iv License # Ab tib Phone <br /> Call,.lf'c <br /> TYPE OF WORK (Check): NEW WELL I-LKDEEPEN '/ / RECONDITION / / DESTRUCTION FT --� <br /> PUMP INSTALLATION / / PUMP REPAIR / /—PUMP REPLACEMENT /- <br /> Other /-7 — +� <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TkNK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ` <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> t/Domestic/private Drilled Dia. of Well Casing Af <br /> Domestic/public Driven. Gauge of Casing Q <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout - <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT.� / / State Work Done ¢ <br /> 6 PUMP '�.EPAIR: j / State Work Done <br /> i <br /> DFCTRUCTION 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 rue to the best of,my knowledge and belief. <br /> � s <br /> y SIGNED Z- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) , <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I <br /> APPLICATION ACCEPTED .BY t DATE �/�' -73' ADDITIONAL COMt1ENTS:, ; 4` LIJAZEE a <br /> PHASE II GROUT INSPECTIOi PHASE III INAL INSPE TIO <br /> INSPECTION BY f;�° DATE [97� INSPECTION BY DATE f� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ' r.+ rr I r n r_ <br /> K/711- � <br />