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L� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I+`Ok..OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� c) <br /> THIS PERMIT-EXPIRES 1 YEAR-` ---- --(Complete In Triplicate) SUED Date Issued �'� 3 <br /> .FR_OM DATE IS„ <br /> Application is hereby made to the San Joaquin Vocal Health District for a permit to construct <br /> and/or install the cork 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 Dist; ict. <br /> JOB ADDRESS/LOCATION CENSUS TRACT �l <br /> Owner's NameN7) Phone <br /> Address --7'7-7G �� q � � City ' <br /> Contractor's Name --- - --License <br />' TYPE OF WORK (Check) : NEW WELL '// DEEPEN '/_/ RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR'/ / PUMP REPLACEMENT /_7 <br /> Other <br /> i` DISTANCE TO NEAREST: SEPTIC TA:ITK/D 0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /s--t> CESSPOOL/SEEPAGE PIT OTHER <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br />` <br /> Ir44ustrial 1 able Tool Dia. of Well Excavation V <br /> omestic/private i Drilled Dia, of Well Casing -Zt> - -- <br /> Domestic/public I Driven Gauge of Casing /0 <br /> Irrigation Gravel Pack Depth of Grout Seal Z50 _ <br /> Other Rotary Type of Grout <br />{ <br /> 1 Other Other Information <br /> PUMP INSTALLATION: Contractor ��� �� <br />,l <br /> Type of Pump H.P. <br /> I' F <br />' PUMP REPLACEMENT: / / State Work Done <br />` PUMP 'ZEPAIR. '~ /% State Work Done <br /> ,DF.-TRUCTION OF WELL: Well,Diatneter 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 .-L c�_ + TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I //� � 1 - - - - -- - -- <br /> APPLICATION ACCEPTED BY � � r DATE � '�� -7j_�___ <br /> ADDITIONAL COMMENTS: } <br /> PHASE• II GROUT ;INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE 9' / - 3 INSPECTION BY DT - Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> " E H 1426 5/731M <br />