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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0F..OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> E Telephone: (209) 466-•6781 <br />€ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> F <br /> T UIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l--f-]3 <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 /> i County Ordinance No. 1862 and the Rules andnRe ul tions the San Joaquin Local Health District. <br /> ./ tC1 <br /> Jos ADDRESS/LOCATION I 7 �4ENSUS TRACT <br /> Owner's Name /�, G �- �� r PhonQ/ Z rV 7` <br /> f <br /> 1 <br /> Address 1 7d ,L., a ,�� City ' <br /> - `1--- - �L�-� L-A_ <br /> i` Contractor's Name jilt <br /> r , License # J� 3 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION DESTRUCTION (7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/_PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 0 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable Tool Dia.. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other , Rotary Type of Grout <br /> 3 - - Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> t Type', of Pump H.P. <br /> PUMA REPLACEMENT: / / State Work Done <br /> --- 1'iJMP F'tEPAIR: State-Work_ Done <br /> ,DF T'RUCTION OF WELL: Well�Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree td 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 workon a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT o£ .thelwell and notify theca before putting the well in use. The above <br /> information is true to they est of my knowledge and belief. <br /> SIGNED TITLE r <br />- (DRAW O LAN ON REVERSE SIDE)'. <br />!� PARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BYE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRAy INS Eal0i PHAS NSPECTION <br /> INSPECTION BY D E INSPECTION BY DATE <br /> CALL FOP, A GROUT IN <br /> PRIOR TO GROUTING AND FINAL INS 'V <br /> P#�4- <br /> F x 7L�2A Y K/71im <br />