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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: V11�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 - <br /> 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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4 Z c7 CENSUS TRACT <br /> Owner's Name `��f i"7��/� '�. d7/(/ Phone <br /> Address U�� �d SZ_ City ' ' <br /> Contractor's Name /� i ,.� �`1 d �'7 c4 1-� (ZP d, License # 30hone y/ 7-/,p <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN %% RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC' TANK 2�.ee SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Z 4-e CESSPOOL/SEEPAGE PIT�` OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Tool Dia. of Well EkcaVation lJ I ,, _ C, - <br /> 2CDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven 'w*Gauge of Casing <br /> Irrigation Gravel Pack- Depth of Grout Seal S U/r A/u:5 u <br /> � .c <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump R-.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DFgTRUCTION 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 i <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. j <br /> SIGNED - TITLE <br /> - - - (DRAW PLOT PLAN-ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> i <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE I GROUT INSPECTION PHASE T I FINAL INSPECTION <br /> INSPECTION B . DATE 7v INSPECTION BY �. DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - -- _ - 5/731M �,' <br />