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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��_ l/2 <br /> THIS PERMIT EXPIRES I 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 described. ' This application is :Wade 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 ��Q t L S 412 .2 �L� I�l7 ---- - CENSUS TRACT <br /> Owner's Name U LLG T 1?A l L R vl L1-4 Phone 0/ 3�/--y SS'9 <br /> Address L--/ '2. i o WIf 4.L e /2 City S T!C/f/ <br /> Contractor's Name License #;;r, 5-7e r Phone q66�,q e 3�z <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /—/ DESTRUCTION / <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES PIT PRIVY <br /> 4 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 /> X 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 ' A.P. / <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP TtEPAIR: I 1 State Work Done <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 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 <br /> PLOT PIAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IL�KTLZNSPECON/ PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ^� <br /> E H 1426 5/731M C1a%. <br />