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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> PLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No.u� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSdED Date 'Issued <br /> (Complete In Triplicate) <br /> Application is hereb 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 -incompliance with San Joaquin <br /> County Ordinance No.,1862"and •the ,Rules and Regulations o;f the Sats Joaquin total Health District, + <br /> JOB ADDRESS/LOCATION C20 4 A 'CENSUS TRACT <br /> Owner's Name . .lfc.0 ..-�:::.. - ¢ ' : Phone' ' <br /> Address � t c�,.c�, -.-- .. City ' <br /> Contractor's Name License # 14,237.3 Phone lis <br /> k TYPE,OF WORK (Check):., NEW. WELL /? .DEEPEN 4-77 'R'EC&DoiTION'�r/_-7- IIESTRb TI6W /_7 <br /> PUMP INSTALLATION /-7 PUMP REPAIR Z/ PUMP REPLACEMENT /7 <br /> Other <br /> l DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i 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 /> f Other Rotary Type" of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> L <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: _4T/ State Work Done � . <br /> 2!ST-RUCTI_O_N 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 <br /> ; information is true to the best of my knowledge and belief. <br /> } SIGNED 'n.e -TITLE <br /> L,,;A._, L <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY DATE �-- <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION PHAS$ II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION $ <br /> E R 1426 7172 1M <br />