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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE. OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3� P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued OL `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 wade in compliance with San Joaquin <br /> County Ordinance Now 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> � <br /> JOB ADDRESS/LOCATION �`L 7e� /✓J %o/ . CENSUS TRACT <br /> Owner's Name ! .''-C � - ✓ Phoneq,?f f `l <br /> Address 'T 7 ( afl:�,.g-7looq -4— <br /> Contractor's Name c� License # ZLL323 Phone FS <br /> TYPE OF WORK (Check.) : NEW WELL / / DEEPEN/ / RECONDITION /—/ DESTRUCTION /`7 <br /> PUMP INSTALLATION /C- 'UMP REPAIR /—/ PUMP 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 CONSTRUCTION SPECIFICATIONS <br /> 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 /> - - Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: /97 State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DF9TRUCTION 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 - v TITLE <br /> (DRAW PLOT LAN 6N REVERSE SIDE <br /> PHASE I FflR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY D 1l- <br /> ADDITIONAL COMMENTS: _.�_.. <br /> PHASE II GROUT INSPECTION PHA F 19SPEGTION <br /> INSPECTION BY DATE INSPECTION 9&7 <br /> DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN <br /> E H 1426 K/.7 ;1m <br />