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-- � SAN JO,AQUIN LOCAL HEALTH DISTRICT <br /> 07LOFFICE USE: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z3- .51eu' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ��7 7 <br /> (Complete In Triplicate) �8_�to-ay <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 /> JOB ADDRESS/LOCATION '" ' -` CENSUS TRACT - <br /> Owner's Name r. Phone _Z21i <br /> Address -Z City- <br /> Contractor's Name glv6 /^ ,:,7 License # 3 Phone ' <br /> cO? 5� 3 <br /> TYPE OF WORK (Check): NEW WELL/T; DEEPEN/_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT // <br /> Other ./—/ N <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavations <br /> Domestic/private Drilled Dia. of Well, Casing 14" _ <br /> Domestic/public Driven Gauge of Casing /..,4" <br /> V Irrigation ✓ Gravel Pack Depth of Grout Seal ;�rD --- <br /> Other -�/ Rotary Type of Grout <br /> Other Other Information 51,o b —A <br /> [j_ <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type: of Pump H.P. . <br /> PUMP: REPLACEMENT: - State- Work,Done- <br /> PUMP <br /> one ..PUMP UPAIR: / / State Work Done <br /> ,DFCTRUCTION 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 an 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 t e best of m^nowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW L PL N ON REVERSE SIRE) <br /> PHASE I DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE /t /e�-7.� INSPECTION BY DATE.9-'may-7� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. C <br /> E_H_1426 5/731m <br />