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SAID JQAQUIN LOCAL HEALTH DISTRICT <br /> F74_F.7OF ICL USE: _ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: (209) 466-6781 <br /> APPLICATION' FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T1�61) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE "ISSUED bate Issued . / 7�/ <br /> 1 (Complete In Triplicate) / <br /> Application is hereby made to the San Joaquin Local Health'District for a permit to construct <br /> and/or ins all the work erein described. * .'his -application is made i ompliance.with San Joaquin., <br /> County Ordinance No. 62 and the Rules and Regulations of the San Joaq n Local stealth District. <br /> a . .SzLkRtdSUS TRACT <br /> Owner's Name !i&l LAdft t Phone ���- l7 <br /> Address City ' <br /> Contractor's Name WTV .t/y, License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / ! PUMP REPAIR l I PUMP REPLACEMENT /7 <br /> Other / ! A <br /> — <br /> DISTANCE TO NEAREST: SEPTICTA14K SEWER LINYS PIT PRIVY <br /> SEWAGE DISPOKAL7IELD C S P OL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> �,Lrable Tool Dia. of .Well Excavation <br /> _=,__�omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 42 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor '4V C (A,pa-66f <br /> Type of Pump H.P. <br /> -PUMP_REPLACEMENT: - - /:-/--,State Work-Done- <br /> PUMP. U-PAIR: / / State Work Done y <br /> DFGTRUCTION 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 notify them before putting the well in use. The above <br /> information true to he bes my nowledge and belief. <br /> � w ' <br /> SIGNED IVTITLE <br /> (DRAW Pa PLAN ON REVERSE SIDE <br /> FOA&EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE <br /> ' ADDITIONAL COMMENTS <br /> PHAS II GROUT INSPECTIOV PHASE III/FINAL INSPECTION <br /> INSP _BATE _ INSPECTION BY DATE /[S <br /> t <br /> CALL FOR A GROUT SPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E HH 142A r�/7gty `7 <br />