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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOt. O1'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 465-5781 <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _?_rr <br /> THIS-`PERMIT'4EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In 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 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 p-t er p ale CENSUS TRACT , <br /> Owner's Name ] m <br /> 44 Phone <br /> Address " /c G r� = <br /> pity <br /> Contractor's Name License #/9.3 7).-1—Phone ci6C -A <br /> �I <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION t7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR /—/ PUMP REPLACEMENT ET! <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER) <br /> G] <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack, Depth of Grout Seal <br /> Other i. Rotary Type. of Grout <br /> Other Other Information <br /> PUNS' INSTALLATION: Contractor u, <br /> Type of Pump . _ G/li <br /> PUMP REPLACEMENT: State Work Done / e <br /> PUMP UPAIR: SQ A/ae �• �.araf,�^.t*rm a7r3t ' <br /> / State Work Done <br /> ,DF-,TRUCTION OF WELL: Well Diameter ' Approximate Depth --Y <br /> Describe Material and Procedure <br /> I hereby agree to comply with all ,laws and regulations of the Sax: Joaquin Local Health District <br /> and the State of California pertaining to or regulating wel.l "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 be my Howled-g and belief. <br /> SICNE TITLE /^g <br /> (D PLOT. PLAN .0 EVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE 3_— / <br /> ADDITIONAL C01MMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE" <br /> CALL FOR A-GROft:-INSPECTION�PRIOR -TO GROUTING AND FINAL-INSPECTION. - - <br /> E H 1426 <br />