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17 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .f• -7S <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. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I /e4 5n��er- <br /> Jos ADDRESS/LOCATION Al CENSUS TRACT <br /> Owner's Name <br /> Phone 3 -, a 2 / <br /> Address 3200 S N I a 461 City <br /> Contractor's Name GG <br /> License # ;t6$-Z4)Phone <br /> TYPE OF WORK (Check): NEW WELL //-k7 DEEPENs <br /> / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / ^'Pi,Wp REPAIR /% PUMP REPLACEMENT <br /> Other /% r /� <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LTNES � PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/ <br /> SEEPAGE PIT OTHER <br /> 1 i <br /> INTENDED USE TYPE OF WELL a A <br /> Industrial ' -�-- CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> DomDomestic/private Drilled x Ilia. of Well Casing ' <br /> Irrigation <br /> Driven Gauge of Casing -* <br /> Irrigation R ___ Gravel'Pack Depth of Grout Seal ' <br /> Other _ Rotary Type of Grout <br /> Other <br /> Other Information <br /> a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump $_LCAff H.P. ! <br /> PUMP REPLACEMENT: / / State Work Done <br /> r <br /> PUMP 'tEPAIR: /-7 State Work Done <br />,DRGTRi1CTI0N OF,WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I herebya gree to comply with all laws and regulations of the San Joaquin Local Heakth District ! <br /> and' the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completioil of my work ona 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 my knowledge and belief. <br /> SIGNED r <br /> i TLE, <br /> (DRAW LOT PLAN ON REVERSE SIDE} . <br /> PHASE I FOR DEPART NT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ZD <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY _10DATE / a <br /> CALL FOR A GROU:r INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON, <br /> E H 1426 lls4V -7 r� <br />