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y <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS.,0FFICE USE: 1601 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 'ISSUED Date Issued �7 <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 r�the Rules and Regulations of. the San Joaquin Local Health District. � <br /> JOB ADDRESS/LQCAT ON / ", ^ ��-��0_C,__•✓•.t <br /> _ CENSUS TRACT 003_-044-fS` <br /> Owners Name �/.2_�� e?F !1!.. .,_•_... Phone -3WZ <br /> Address C'i L City X40 , Gf' -- +-� <br /> Contractor°s Name License # 1/ y Phoned <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION IR' LblP REPAIR -/_/-PUMP REPLACEMENT J_7 <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES P T PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT : OTHER <br /> .. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "( <br /> Industrial Cable Tool Dia. of Well Excavation p <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ! Ear <br /> PUMP REPLACEMENT: State Work Done �. <br /> PUMP UPAIR: / / State Work Done <br /> ,DF'zTRUCTION OF WELL: Well Diameter Approximate Depth 1 <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 <br /> . <br /> (DRAW PLOT PLAN ON REVERSE TSIDE). --- - - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE l <br /> ADDITIONAL COIMMENTS: <br /> P11ASE. II GROUT_INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2�j 7. <br /> i---w CALL .F°DR•A°.GROUT INSPECTION-PRIOR TO GROUTING AND, FINAL INSPECTION. <br />