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SAN .TOA4UIN, AL,R HEALTH DISTRICT <br /> OrOFFICE US] . 1601 E. Hazeltb�*yb , .Stockton, Calif. <br /> Telephone.:: ('209)`=:'4:66-6781 <br /> APPLICATION FOR WELL.-CONSTRUCTION OR PUMP PERMIT Permit No.------------------------------------- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 des' ctibed. ' 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. a <br />' F + <br /> JOB ADDRESS/LOCATION �69 CENSUS TRACT <br /> Owner's Names- / p Q Gl�/�.e Phone /7L k2 <br /> Address + ` City , <br /> Contractor's Name /'��.� ! o_r l��r! License #I/ Xf-O Prone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION 1-7 - <br /> PUMP INSTALLATION / f PUMP REPAIR / / PUMP REPLACEMENT ' <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC ;TAivK �✓ �yg(v*`WER 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 s <br /> Other Rotary Type of Grout . <br /> Other Other Information t <br /> r <br /> PUMP INSTALLATION: Contractor eetzc-:� <br /> Type. of Pump H.P. J <br /> PUMP REPLACEMENT: / / State Word° Done <br /> PUMP '2EPAIR: lJcr-�i7 r <br /> State Work Done <br /> DFgTRUCTION OF WELL: Well Diametev°i Approximate Depth- <br /> Describey%Materi,al and Procedure <br /> r. <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 -F <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 +-elti(CTITLE <br /> (DRA PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYt,. <br /> DATE <br /> ADDITIONAL COMMENTS:.3/ <br /> PHASE IfQ3ROUT IlqSPECTIONO P II /Im1IPAL fNSPECTIO <br /> INSPECTION BY DATE INSPECTION BY TE �� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ,- <br /> E H 1426 5/711M <br />