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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,Vf y -,44.) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedj3 <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 Sant Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _f L1 <br /> ENSUS TRACT �I <br /> Owner's Name I�'lf fYl -IAC 1fY1 ------ Phone �¢ 0!!j <br /> Address -• ---,�'�� �� . - - City Za,�7,A <br /> o f <br /> Contractor's Name License lid °� Phone 39 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INS ALLATIO PUMP REPAIR/ J PUMP REPLACEMENT /- <br /> Other / J — <br /> E <br /> DISTANCE TO NEAREST: SEPTIC TANKY0Aj SEWER LINES PIT PRIVY �1 <br /> SEWAGE DISP09AL FIELD CESSPOOL/SEEPAGE PIT OTHER Nb <br /> INTENDED USE iTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation Ale .._. <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I_ Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> Other Oth r Inf rmati <br /> arm <br /> PUMP INSTALLATION: <br /> AL ATION• Co rac r <br /> nt to <br /> Type lof Pump _ H.P. <br /> PUMP REPLACEMENT: I / State Work Done <br /> x <br /> PUMP TEPAIR: / / State-Work Done <br /> ,DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> i I hereby agree to comply with all laws and zegul.ations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> 1 after c letion of my work on a new well, I will furnish the San Joaquin Local Health District. a <br /> WELL RILL S REPORT of .the well and notify them before putting the well in use. The above <br /> inform tion is t to the best of my knowledge and belief. <br /> i <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I . <br /> APPLICATION ACCEPTED .BY DATE - <br /> ADDITIONAL COMMENTS: <br /> I PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY -DATE INSPECTION BY ��� DATE /b -1V-7.3, <br />'a - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />