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SAN JOAQUIN LOCAL 4EtgTH DISTRICT <br /> FOt, OFFICP, USE: 1601 E. Hazelton Ave. , 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 $-t 3 <br /> (Complete In Triplicate) Op-Co-4,-7,0 -0 / <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 Regulations of the San Joaquin Local. health District. <br /> JOB ADDRESS/LOCATION O Q� p / ® CENSUS TRACT <br /> Owner's Name 47-.44,11 /0- Phone <br /> Address _ 90 72 IV 1%L1 Zd p-,v —Cg City007 <br /> Contractor's Name �.,- License #/& �hone <br /> OP <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> IN'T'ENDED 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: X State Work Done f <br /> _ V <br /> PUMP UPAIR: / / 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 ef. <br /> SIGNED .j <br /> (DRAWMT PLAN ON REVI" 5IDE) � <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I — _ <br /> APPLICATION ACCEPTED BY. DAT} <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PHA III/FINAL SPEC ION <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN PECTION. i�l 73�� Cr <br /> E 11 1426 _ _ / of M/73iM <br />