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I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FT-br :OFk10E 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) <br /> Application is hereby rade 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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION w -- .�.'f�F87 a.�!L � e,n 1� _oCENSUS TRACT <br /> owner's Name i .� .�, tv oC � - - -_ Phone <br /> Address _ 14 9 0 city , . <br /> Contractor's Name .t�. License # Phone <br /> F <br /> S <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION /—/ DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other ./—/ — — <br /> DISTANCE TO NEAREST: SEPTIC TA14K SEWER LINES PIT PRIVY Qv, <br /> y� <br /> ' SEWAGE DISPOSAL FIELD ,� CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial EI Cable Tool Dia. of Well Excavation S ` X <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _ 00.7 ---- <br /> Other Rotary Type of Grout <br /> Other Other Information i <br /> 4 <br /> - s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H . - 7 <br /> PUMP_ REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DFARUCTION 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 f <br /> information is true to the best of my knowledge and belief. <br /> t f. <br /> SIGNED TITLE . ` <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR ,ARTMENT USE ONLY <br /> f' <br /> PHASE I <br /> APPLICATION ACCEPTED .BY (2- ` _-DATE <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE ,II'I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />' f <br /> CALL FOR A GROUT INSPECT,T0�IRIOR TO GROUTIN AND FINAL INSPECTION. <br />