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+` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE: FFICE 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 <br /> (Complete In Triplicate) -2C3- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> f and/or install the work herein described. - This application is made in compliance with San Joaquin <br /> County Ordinance No. 8 and the Rules and Regulations o£ the San Joaquin Local Health District. <br /> ;,,,,. <br /> JOB ADDRE S/LOCATION v fZ CENSUS TRACT <br /> Owner's Namenez <br /> City <br /> Contractor's <br /> Address 6 A , L-z t- a", <br /> Contractor's 'Name icense # Phone <br /> TYPE OF WORK (Check): NEW WELL /J DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PG'MP REPAIR '/ / PUMP REPLACEMENT /_7 GV <br /> Other <br /> DISTANCE TO NEAREST: 4SEPTI . TANK,00 SEWER LIKES PIT- PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> � /,p �. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial f Cable Tool Dia. of Well Excavation <br /> Domestic/private # Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other # Rotary Type of Grout 7 'JLGF E� <br /> r Other Other Information 6-lab - U 1220ttj <br /> PUlT INSTALLATION: Contractor <br /> Type sof Pump H.P. ' <br /> PUMP REPLACEMENT: _ <br /> / / State Work Hone <br />"--PUHP 'tEPAIR: = . • �/: $to to Wo ric Done _ .. _—;r _ _ <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <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 to the best of my knowledge and belief. <br /> SIGNED itilgJL TITLE <br /> t ( W PL PLAN ON RE RSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> IAPPLICATION ACCEPTED .BY DATE Z <br />' ADDITIONAL COMMENTS; <br /> PHASE II G TkINSP Oi PWLIA NAL INSPECTION <br /> INSPECTION BY -30 INSPECTION DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.`'"" <br /> E H 1426 5/.71 im <br />