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SAN JOAQUIN LOCADI�TBICT-- n <br /> FOF.:OFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> PEEt �O6' <br /> Telephone: (209) 466-6781 tz"¢D / — `��,w�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT, / rKPKP mift6' . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -Y/- <br /> (Complete <br /> 7 <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION y (� /y�r rr� t ( CENSUS TRACT <br /> Owner's Name JQ 6Lnn lc ( S Phone 40 - 5-30 <br /> / <br /> Address S 2 e City <br /> Contractor's Name y. P License A Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /Y DESTRUCTION <br /> AL <br /> PUMP INSTLATION PUMP REPAIR/ / UMP REPLACEMENT <br /> Other "/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED 'USE TYPE OF WELL r CONSTRUCTION SPECIFICATIONS vt <br /> Industrial �'f„�� Cable Tool Dia. of Well Excavation cC <br /> Domestic/private Drilled )Da:tof Well Casing \1 <br /> Domestic/public Driven Gauge ofj Casing- - --.,." - <br /> Irrigation Gravel Pack t Depth of� Grout Seal <br /> Other t Rotary Type`of-Grout <br /> ! Other Other Information 1 ' <br /> 1 <br /> PUMP INSTALLATION: Contractor i - <br /> Type of Pump 1 H.P. <br /> PUMP REPLACEMENT: /i / State Work Done I 'i <br /> PUMP 2EPAIR: /, / State Work Done <br /> DFsTRUCTION OF WELL: Well Diameter fl y 1 "�� Approximate Depth 0 r <br /> �jescribe //,M�aterial and/-Procedure 1 ( " r t ve <br /> T6 � f rf b'r. S H,.r T alc e I -1 1 a_I t j r-e n A- Lc <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 willlfurnish the San Joaquin Local Health District <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 belii ef. <br /> SIGNED } TITLE - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT. USE ONLY <br /> 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 INSPECTION. <br /> E H 1426 5/731M <br />