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�j V � <br /> `- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk.,OFFS.CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: 1(.209) 466-678 . ' <br /> ,APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7fo_ -�il <br /> THIS PERMIT EXPIRES11. YEAR FROM DATE ISSUED Date Issued <br /> (Completd In Triplicate) <br /> Application is hereby made to the San Joaquin:!�Local Health District for a permit to construct <br /> d. * This application is made in compliance with San Joaquin <br /> and/or install the work herein describe <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION � �'G62T. MA02 � <br /> CENSUS TRACT <br /> Owner's Name !1�U 1 ( Phone p2p <br /> Address �2 Co. i City <br /> i <br /> Contractor's Name License # Phone <br /> TYPE'OF WORK (Check) : NEW WELL / / , DEEPEN I��/ 'RECONDITION_/ / DESTRUCTION /7T <br /> PUMP INSTALLATION J PUMP REPAIR / / PUMP REPLACEMENT 17j ;Other J `f f ti �. <br /> DISTANCE TO NEAREST: SEPTIC TA&114K SEWER LINES _. PIT PRIVY <br /> SEWAGE DISi'QSAL FIELD 's CESSPOOL/SEEPAGE PIT OTHER \ <br /> if <br /> f INTENDED USE TYPE OF WELL - J CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tooli Dia. of Well Excavation <br /> Domestic/private — Drilled Dia. of Well Casing "k <br /> Domestic/public Driven Gauge of Casing <br /> < Irrigation Gravel Pack Depth/of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other .Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Urzn <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> k _PUMP&,`tEPAIR: / J State Work Done <br /> DFzTRUCTION OF WELL: _ Well Diameters , • �, . r 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 /> 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 m knowledge and belief. <br /> SIGNER TITL J/ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE I 7i Jf <br /> ADDITIONAL COMN!ENTS: �M <br /> k PHASE ,II GROUT INSPECTION PHASE FAN INSPECTIgy <br /> j INSPECTION BY DATE INSPECTION BY DATE <br /> I CALL FOR A GROUT INSPECTION- PRIOR TO GROUTING AND FINAL INS KCTION_ <br /> _ . _ _ 1 5/731M <br />