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4 r y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0FOFFICE USE.- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,r�._3aZ3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�r7q <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. � <br /> h <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> l 7 2-'0 <br /> Address Q Z ' <br /> City <br /> Contractor's Name (T License #-200 79*Phone 41 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /K <br /> PUMP INSTALLATION ../X PL`MP REPAIR / / PUMP REPLACEMENT /-7 ..�� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TA;VK 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 - � Aff <br /> Domestic/private Drilled Dia. of Well Casing 1, {, d <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal P <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. / L <br /> PUMP REPLACEMENT: j / State Work Done <br /> PUMP REPAIR: / / State Work Done _ <br /> rl <br /> .DFfiTRUCTION OF WELL: Well Diameter Approximate De th -- <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 ! n TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F09,UMrAXTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE lj4hLl <br /> ADDITIONAL CO]IMNTS-* <br /> PHASE II GROUT INSPECTIONkHR HASE I /FINAL NS TION <br /> INSPECTION BY DATE -mac - _ INSPECTION'B ,.:, DATE <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FIIi INSP ION. <br /> E H 1426 5/731M <br />