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y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:OIFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z .;Ah! <br /> THI'S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3- <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 h San Joaquin Local fied1th District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Q Phone <br /> /oaa <br /> Address City <br /> Contractor's Name License on <br /> TYPE OF WORK (Check) : NEW WELL f <br /> DEEPEN '/-7_ RECONDITION I / DESTRUCTION lrT <br /> PUMP INSTALLATION PU` ff' REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC T&W SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> --�,r Indus-irial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing JAL Z <br /> Domestic/public Driven Gauge of Casing j <br /> Irrigation -� Gravel Pack Depth of Grout Seal. � <br /> Other 'Rotary Type of Grout 1 <br /> Other Other Information f <br />' 1 <br /> i. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / f State Work Done <br /> DFgTRUCTION OF WELL: Well. Diameter � rr 30 r Approximate Depth ? <br /> r <br /> Describe Material and Procedure hjAtjg 'iiti as-e- fW'1044 _ <br /> I hereby agree to comply with all lawns and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "construction. Within VIFTEEN 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 -7�7 <br /> APPLICATION ACCEPTED �✓►�. DATE �/ / / <br /> ADDITIONAL COMMENTS: <br /> PHA I OROU INSPECTION PHASE I /FIN INSPECTION <br /> $ INSPECTION BY DATE - - 77 INSPECTION BX DATE 3-/ --7 <br />{ CALL FORA GROUT INS-PE T�p PRIOR TO GROUTING AND FINAL INSPECTION. <br /> c-t-� TN nisi c,.c�rP 5/731.M <br />