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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave- , "Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Not 3/3 P <br /> C4 3— 2s o— r O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued <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 k9gula ions the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �j �i� I' .J 1 � , wA.�/ �,C' +�`1 CENSUS TRACT <br /> N : <br /> Owner's Name p `� <br /> Phone N <br /> " IV` s <br /> Address 3 /4 -� ;� <br /> City (n <br /> ' A <br /> Contractor's Name . License Phone ` <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN _j RECONDITION /_7 DESTRUCTION /� <br /> PUMP INSTALLATION A PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> Other / / i' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> � SEWAGE D SPOSAL FI D CESSPOOL/SE G TT 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 /> / ! 11t er <br /> PUMP INSTALLATION: - Contractor �G��.� t <br /> Type of Pump t ,, H.P. <br /> PUMP REPLACEMENT: / / State Work Dane <br /> 3 <br /> PUMP REPAIR: / / State Work Dome { <br /> e,4-"_' ..� c vec <br /> EESSTRUCTI_ON OF WELL: Well Diameter s.c 66, Approximate Depth <br /> Describe Material and P ` cedure <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 FIF'T'EEN 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 true to the best of my knowledge and belief. <br /> SIGNED , 41-1-11-- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> r <br /> PHASF,.II GO NS C PRASE II FINAL INSPECTION <br /> INSPECTION BY v DATE V INSPECTION BY DATE 2-it! z r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 � im <br /> - � r <br />