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L SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> F'OF. OF��ICE USE: 1.601 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 'I.SSUED 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. 1662 .and the Rules and Regulations of the San Joaquin Local Health District. <br /> Boa ADDRESS/LOCATION <br /> CENSUS TRACT - <br /> owner's <br /> RACT "Owner's Name L2zrz " Phone <br /> CityAddress ✓ <br /> Contractor's Name- ,,J - a� License # Phoned <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN/ / RECONDITION_ /_/ DESTRUCTION / <br /> PUMP INSTALLATION / / PZ;M'MP REPAIR / / PUMP REPLACEMENT <br /> other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS = <br /> Industrial Cable Tool. Dia. of Well Excavation C �}F <br /> Domestic/private Drib-ledDia-.-of-Well Casing <br /> Domestic/public Driven Gauge ofCasing .� <br /> Irrigation "Gravel Pack Depth ofiGrout Seal <br /> Other 'Rotary Type-of- Grout <br /> Other Other Information ' <br /> PUMP iNSTALLATION: Contractor - <br /> Type <br /> ontractor -Type of Pump �. �. H.P. ' J <br /> PUMP REPLACEMENT: / State Work Donear�/�/� 1911 sof <br /> PUMP UPAIR: / / State ,,Work Done' . <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure. - --- <br /> I berebyfagree to comply with all lairs-and regulations of the San Joaquin Local Health District <br /> and the .'State. of California pertaining ta'aY 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 rlawledge and belief. <br /> SIGNED I '� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I E <br /> APPLICATION ACCEPTED .BY___�/za DATE <br /> ADDITIONAL CdNXENTS: _ <br /> 'PHASE Il GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE p 4 <br /> -CALL 40R°A GROUT-INSPECTION-PRIOR,-TO GROUTING -AND FINAL INSPECTIO . <br /> E H 1426_ : 5 731I�i_ , . <br />