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rte- --.• <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rOF. Ol'1 TCE U5E: v 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �}'$1OiQ?• <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued o <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �,, $� C.y �tv_y �� �+ CENSUS TRACT <br /> Owner's Name ��� -� - Phone cr ,:f /f�87 <br /> Address aC�/o2 Wa-o-rY_� � _ City <br /> � <br /> LicensePhone <br /> Contractor's Name � %S <br /> TYPE'OF WORK (Check): NEW WELL j <br /> U DEEPEN/ / RECONDITION / / DESTRUCTION /rT <br /> PUMP INS / / PUMP REPAIR / I PUMP REPLACEMENT I_T <br /> _ <br /> Other / / <br /> DISTANCE TO NEAREST SEPTIC TK SEWAGE DISPOSAL FIELDER LINES PIT <br /> PIT OTHER <br /> U <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL C <br /> Industrial Cable Tool Dia. of Well Excavation I <br /> y' Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing S <br /> irrigation Gravel Pack Depth of Grout Seal .S o ' — <br /> Rotary Type of Grout <br /> Other A .- Other Other Information <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of'`Pump _ 9� o H.P. 2-- <br /> f <br /> PUMP REPLACEMENT: / / State Work Done - <br /> PUMP REPAIR: <br /> I/ <br /> State Work Done <br /> _ApproRima 'erDepth <br /> DF-TRU OF WELL: Well Diameter . � <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the. San Joaquin Local Health District <br /> i rtaining to or_regulating well''construction. Within FIFTEEN DAYS <br /> and the State of California pe <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 /> ( �DEpARTMENT <br /> TITLE <br /> SIGNED (DRAW PLAN ON REVERSE SIDE <br /> FOR USE ONLY <br /> PHASE I DATE <br /> �... APPLICATION ACCEPTED .BY <br /> ADDITIONAL CO01ENTS: - PHASE III/FINAL INSPE�07­ <br /> INSPECTION <br /> PHASE II GROUT INSPECTION"" INSPECTION BY DATE BY DATE <br /> CALL FOR A. GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731M <br /> t E H 1426 <br />