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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL. 01 k ICE USE': / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.Ty 41-z±0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued$1_11r / <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 _XkdZ CENSUS TRACT <br /> Owner's Name �.► !P� -- - -- Phone <br /> Address City <br /> Contractor's NameP�__IZA7eLicense # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION f_1 DESTRUCTION <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEME <br /> ALNT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES r PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _.,foz 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 /> PU:9P INSTALLATION: Contractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ',EPAIR: f j State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter e__11_1 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY a /ll�t DATE <br /> ADDITIONAL =Z1ENTS: - <br /> pV TY F PHASE r1I/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE. L <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />