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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton.Ave., yStockton, Calif. <br /> Telephone: (209) -466-6781 <br /> PLICATION FOR WELL CONSTRUCTION`OR PUMP PERMIT Permit No.'/� ' <br /> THIS PERMIT EXPIRES 1- YEAR:FROM­DATE.r,ISSUED-vs- :'Date Issued <br /> (Complete -In�Trip li'c'ate) <br /> Application.:is.:3hereby,made:.to .the San-�J.oaqu n�.Local .Health Drst.rict!f'or a-pefmit to. construct <br /> and/or install the work herein described. This:,applicatkon,'i's made'.:in-,compliance with :San` Joaquin` <br /> County.Ordinance,Na 1862.:and-the.Rules-)and •-Regulations-,of.cthe, Safi:Joaquin Local Health District. <br /> 0'0 3_ -22-0-0- <br /> JOB ADDRESS/LOCATION <br /> PCENSUS, TRACT <br /> F ' <br /> ° X �.C7is� .y �. <br /> Owner!ssNaITle11 :7 <br /> •Phone7� <br /> Address <br /> City . <br /> ' Contractor's Name Li <br /> _- x <br /> • cense � ��� Phone `r <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /% RECONDITION /�/ DESTRUCTION /_7 <br /> PUMP :INSTALLATION J / PUMP REPAIR/ / PUMP REPLACEMENT /7 41 <br /> Other J% <br /> r <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE . TYPE WELL CONSTRUCTION SPECIFICATIONSf <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> �,. omestic/private Drilled Dia. of Well Casing �a <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of. Grout Seal : 6 E <br /> Other Rotary Type of Grout �. <br /> Other Other Information Rf <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump H.P. <br /> + _ <br /> PUMP REPLACEMENT: / / State Work Dona r <br /> PUMP REPAIR:_ /-7 State Work Done w �. <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <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 _- _1--L C TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE II <br /> APPLICATION ACCEPTED BY DATE - ` -Z7--- <br /> ADDITIONAL COMMENTS x <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY _ DATE 9-7Zi <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIbN. ' <br /> E H 142b 4/72 IM <br />