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SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> FOf,,-'OF ICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. # <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�2-[.I61 <br /> 7V - <br /> THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 a ulations of the San Joaquin Local. Health Disrri.ct. <br /> JOB ADDRESS/LOCATION CENSUS TRACT , <br /> Owner's Name � - Phone <br /> Address C6�?e;t� er A/ -'f City , <br /> � tP �iore3 <br /> Contractor's Name ,L_ License 4 I.D�Phone <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN/ / _RECONDITION / I DESTRUCTION IT <br /> PUMP INST—ALLATION /-2 PUMP REPAIR'/ / PUMP REPLACEMENT /� <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LIVES <br /> SEWAGE DISPOSAL FIELD 'CS5POOL/SEEPAGE PIT In, c� OTHER •-- <br /> r ,y i. <br /> INTENDED USE TYPE Of WELL ' '� ...k ,CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia, of W&11 -Excavation 6 <br /> mastic/private Drilled _Dia,,.,of Well-,Casing l <br /> Domestic/public Driven Gauge of Casing ZZ <br /> Irrigation Gravel. Pack Depth of Grout Se CJ 0-7- <br /> --k--���`-�_ <br /> Other teay• . _- Type.-of Grout <br /> Other Other Information <br /> x <br /> f PUMP INSTALLATION: Contractor <br /> f Type of Pump +� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: I� State Worr k Done <br /> ,DFGTRUCTION OF WELL: Well Diameter Approximate .,Depth <br /> Describe Material and Procedure <br /> 1 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin -Iocal 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 /> informs is true to the best ow dge and belief, b <br /> SIGNED j TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> P11A E.1DATE <br /> APPLICATiO EPTED .BY f _ <br /> ` ADDITIONAL COMI✓MNTS: <br /> PHASE II, GROUT INSPECTION 1PHAS I / �TAL INSPECTION <br /> INSPECTION BY ,s. . DATE- <br /> 7 <br /> ATE i INSPECTION BY ATE _)-.21-2S _ <br /> # CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> - - - L , - r- . - 5/731M <br />