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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS'. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued �g �9 Jj <br /> (Complete In Triplicate) <br /> Application is hereby made o 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 witth San Joaquin <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> _q. 4-9 � jL All wA. Y-.2- ( �. cENsus TRACT. <br /> Owner's Name U,_AL�eL /y4 S Phone <br /> Address j ,j q� ' E f���/4 �/ .2 City <br /> Contractor's Name / License #2"(�L Phone 4-e64gS35;� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> AL <br /> PUMPJINSTLATION / / R <br /> PUMP REPAI /—/—PUMP REPLACEMENT <br /> 0 ther ./ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (J1 <br /> INTENDED USE ITYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> t Other Other Information ' <br /> Pn1P INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done p <br /> PUMP `tEPAIR: / / 'State Work Done <br /> DESTRUCTION 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 /> F WELL DRILLERS REPORT of .thelwell and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> i <br /> f <br /> SIGNED <br /> ./Z� .u.�/�4f_J� „PI.OAz � T ITLE <br /> T AN ON REVERSE SIDE <br /> r - <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED BY DATE (_ <br />' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 5/731M 673 <br />