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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:OFIICE 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 I YEAR FROM DATE 'ISSUED Date Issued7c� <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 the San Joaquin Local Health District. <br /> 'T_# r <br /> JOB ADDRESS/LOCATION CENSUS TRACT 2-48 - 'OTO:27 <br /> Owner's Name 14Q O �Sa Phone <br /> Address- - L7 .0 �� City <br /> t <br /> Contractor's Name License Phone ' <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /7 CIVPUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ITT N <br /> Other / ! SI (01.FL L �.4L c - SGt ert,4G __5 - -- <br /> DISTANCE TO NEAREST: SEPTIC TIUNK 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 Excavation <br /> Domestic/private ' Drilled Dia. of Well Casing S <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 /> I PUMP INSTALLATION: Contractor <br /> III 'Type of Pump <br /> PUMP REPLACEMENT: / f State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> t DF-,TRUCTION OF WELL. Well Diameter prox--Jmatt 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 /> 'I 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 /> j 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 /> n SIGNED TITLE Rt,,4 /1'I "Al-e�/� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY _^_4 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE3_-� <br /> CALL FOR A•GROUT INSPECTION PRIOR\TO GROUTING AND -FINAL INSPECTION. C <br /> E H 1426 5/731M <br />