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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;74f- �-ffv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9-.1-7 <br /> q�f2 S S`/-OGi�T�� r4✓E , (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. 18 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION u CENSUS TRACT <br /> Owner's Name Phone ..� <br /> Address City <br /> � r <br /> Contractor's Name ' License #_�Zja "V.2�hone <br /> TYPE OF WORK (Check) : <br /> NEW WELL DEEPEN '/ / RECONDITION /_/ DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY `v <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER t7 <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 Casing ; <br /> llUp <br /> Irrigation �� Gravel Pack Depth of Grout Seal <br /> Other ----:[� Rotary Type of Grout <br /> Other Other Information <br /> PUPPP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP 'tEPAIR: /% State Work Done <br /> DFRTRUCTION 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 to the best of my knowledge and belief. <br /> f � " <br /> SIGNED 1f y�ct� TITLE {�r�r•�` Ir N.C, <br /> -- ..(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ef- <br /> ADDITIONAL COP2PIENTS: -- <br /> PHASE I GROUT INSPECTION PHA IL/FINAL INSPECTION <br /> INSPECTION BY DATE /! -P? INSPECTION BY / DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731.M <br />