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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 715T.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 1. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.17 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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. 1862 and the Rules and Regulations of the San Joaquin. Local Heilth Disrri.ct. <br /> f <br /> JOB ADDRESS/LOCATION 2 G 7 't I VER R CENSUS TRACT , <br /> Owner's Name C k Phone <br /> I --- <br /> Address City ifs CO La 4 <br /> Contractor's Name License 11,76At741 Phone 44 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ I RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP �INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other l 1 <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 `V <br /> Industrial, i Cable Tool Dia. of Well Excavation �j <br /> Domestic/private ► Drilled Dia. of Well Casing <br /> Domestic/public ! Driven Gauge of Casing !� <br /> Irrigation i Gravel Pack Depth of Grout Seal ' <br /> Other Rotary Type of Grout <br /> Other _ Other Information ' <br /> C' <br /> PUMP INSTALLATION: Cont actor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP `REPAIR: /_7 State Work Done <br /> DF9TRUCTION 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 /> 1 14ELL 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 /> Ioma' <br /> SIGNED TITLE 5---- <br /> (DRAW'PL LAN ON REVERSE <br />�. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> R! APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR UT INSPECTION PHASE II/ INAL INSPECTION .— <br /> INSPECTION BY DATE INSPECTION B DATE .:2 f�`a� <br /> CALL FOR AV'ZkOUT INSPECTION -PRIOR TO.-GROUTING AND FINAL INSPECTION. !� <br /> E H 1426. c:/71im <br />