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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 2 ' 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 4 I,,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 the Rules and Regulations of the San Joaquin Local Health District. <br /> (230 <br /> JOB ADDRESS/LOCATION ' I&ENSUS TRACT 2-s ? -3dO fZt <br /> Owner's Name F', L?. L- 11a12Gc.'' , . Phone <br /> Address _I _ r x/1!1!1 _�, City <br /> Contractor's Name 40,u� License Y4wPhonFZ_�� <br /> CJ <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/—/ RECONDITION / / DESTRUCTION r j <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 `V <br /> Other/ / W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Data. of Well Excavation <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 c'o--� <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> .DFQTRUCTION 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 /> 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 _ � � _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 4� <br /> APPLICATION ACCEPTED BY �, DATE <br /> ADDITIONAL COUNTS: <br /> PHASE II GROUT INSPECTION PHA /1-1L/FINAL INSPECTION <br /> INSPECTION BY , DATE INSPECTION BY `/ J. DATE 6 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />