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SAN JOAQUIN LOCAL HEALTH DISTRICT, Y <br /> T <br /> � Ug1601 E. Haze7.tan Ave. , Stockton, Ca�.if. <br /> �'. <br /> Telephone: (209) x+66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ;i <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 /> f land/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> 4 !county Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ENSUS TRACT <br /> IJOB ADDRESS/LOCATION <br /> � Phone �•3, <br /> �I Owner's Name �Q.(.C�_ `t"ri _ -- <br /> City <br /> iAddress <br /> ILS <br /> ! ' License # D 1,3 phone <br /> 'IContractor's Name <br /> I .F <br /> "TYPE OF WORK (Check): NEW WELL /� DEEPEN ./ 1 RECONDITION /_/ DESTRUCTION 1-7 <br /> I PUMP INSTALLATION / / PUMP REPAIR I I PUMP REPLACEMENT I? <br /> k r Other / 1 <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 /> I ! u <br /> Domestic/private Drilled Dia. of Well Casing; <br /> Domestic/public Driven Gauge of Casing <br /> i ' Irrigation Gravel Pack Depth of Grout Seal <br /> Other rte/_ Rotary Type of Grout <br /> Other Other Information <br /> 'i PUMP' INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: I/ State Work Done <br /> PLJ�SP'tEP I /+;.-_Statete- <br /> Wor`kTDatie�"'"` '�""""�"-:4 -y.. -•� <br /> # A roximate Depth <br /> h j ,DFRZTRUCTION OF WELL: Well Diameter PP p �-- .--- <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 1 .1 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 j <br /> i WELL DRILLERS REPORT of tkie 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 y (� TITLE17 <br /> f ,� (D PLOT LAN ON REV SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I' { DATE ZSr-7V <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: <br /> i PHASE II N ROUT INSPECTI P I AL INSPECTION <br /> INSPECTION BY DATE INSPECTI BY DATE <br /> �� CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> u z,.I)G 5/731M <br />