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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �'OF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 /> and/or install the work herein described. - This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Reggull <br /> JOB ADDRESS/LOCATION 3,50 tions of the San Joaquin Local. Health District. <br /> IV I�I v 0 J� CENSUS TRACT <br /> C/`� _ <br /> Owner's Name Phone <br /> Address 4:3.5e (.�[/ V /� � _ .#F_ City"/ �� I <br /> Contractor's Name/ r� CJ -- License #/' 3/ahone�-4 6g6N l <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ' _/ RECONDITION /_/ DESTRUCTIO <br /> PUMP INSTALLATION PUMP REPAIR/—/ P NT 1-7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC T SEWER LINES PIT PRIVY <br /> ` SEWAGE DIS OSAL FIELD CESSPOOL/SEEPAGE PIT 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 /> PUMP INSTALLATION: Contractor <br /> a Type of Pump H.P. <br /> PUMP REPLACEMENT: f f State Work Done <br /> PUMP `ZEPAIR: I / State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter Approxima a e th <br /> D ribe Material and Procedur �p ,/N(P <br /> 64,42.0 4/,4j.0 jc t Z, L tJ f ^,,- <br /> I <br /> fI 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.*iotify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> �rd <br />€ J <br /> j SIGNED �}� fz {L1�]� '�? !0 1La-w' TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 1. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECT ON / <br /> INSPECTION BY DATE INSPECTION BY _ � ------ DATE Jd rJ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> s T 17 V�/7'4-tu ` <br />