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SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> FOL OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distract 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 /> .TOS ADDRESS/LOCATION I- O P G A R CENSUS TRACT - <br /> Owner's Name G E $ L 4e,a /z L / 4/ _ Phone 4 <br /> Address 2 G Z/- O PI-A P, city <br /> Contractor's Name License 41 �L d, Phone Z/4 4,,Jg? W <br /> TYPE OF WORK (Check): NEW WELL I I DEEPEN '/ / RECONDITION / /. DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> " Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SE14ER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USETYPE 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 _- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUTM'fi' INSTALLATION: Contractor <br /> Type of Pump K.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP •tEPAIR: '/"C/ State Work Done <br /> .DF-,TRUCTION 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 /> SIGNED ,� TITLE <br /> RAW PL "/ LAN-ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ----- <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION B ATEr- <br /> -CALL FOR A-GROUT INSPECTION PRior TO GROUTING AND FINAL INSPECTION. <br /> - 11 . ,.,, /731M <br />