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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF..'OFFICE USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7'�✓° w F <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued :Y-41- <br /> (Complete <br /> Y-41-(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 Ordinanc o. 18621 an the R Wa, es n egul.ations of the San Joaquin Le Ll veakt]R nist�rict. <br /> 1.4 <br /> JOB ADDRESS/LOCATION r` TRACT " <br /> owner's Name Phone t <br /> Address � itr'7rt,IZ I /' 'LI '�5 City ' " gg <br /> � / � 1 <br /> Contractor's Name L �:. - License Phor1CL19 i <br /> TYPE OF WORK (Check): NEW WELL '/X DEEPEN /% RECONDITION / DESTRUCTION /? ' <br /> PUMP INSTALLATION / / PbW REPAIR / J PUMP REPLACEMENT <br /> Other /_7 — -�- <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 Excavation <br /> Domestic/private =Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of CasingE <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other �otary Type of Grout <br /> Other Other Information <br /> • t <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump H.P. f <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> ,DFgTRUCTION 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 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 <br /> ��t�othe best of my knowledge and belief. <br /> SIGNED �rY/t-C/!I' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _L.^` 7 + <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FIN4 INSPECTION <br /> INSPECTION BY DATE / 7 INSPECTION BY Gv DATE <br /> 3 <br /> CALL FOR A GROUT7IN5PECTION PRIOR TO GROUTING AND IAL IN PECTIfl7��i. �-,�r� j`Z77 <br /> V v �.n c /�pn i!Y' �}/�"'76'J? .4/�! if J r f 7'�1 bf' <br />