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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 No. '3_y38 k� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f-. y- _7 <br /> (Complete In Triplicate) <br /> Application -is hereby made to the San Joaquin Local Health District for a permit to construct <br /> k 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 /> I JOB ADDRESS/LOCATION J /YCf/ C7G CENSUS TRACT <br /> Owner's Name 'lc �l-Cf� ,�a�l Phone <br /> Address l �� 7 W, /,/(9z City <br /> 3 - <br /> Jl� t <br /> Com/ [— l%r/LL./�!!�' V� 1' License #Contractor's Name 117 9 Phone 1��1 �" <br /> ff 1 1 C-.a5-1- Tr- <br /> TYPE <br /> cTYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE T TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �ndustrial t_--table Tool Dia. of Well Excavation <br /> �Comestic/private Drilled Dia. of Well Casing 4" -___ _ � <br /> Domestic/public Driven , Gauge of Casing &I <br /> Irrigation Gravel Pack Depth of Grout Seal Z2 ' <br /> Other Rotary Tyy�L of .Grout- <br /> Other Other Information <br /> 3 � <br /> PUMP INSTALLATION.- Contractor <br /> Type of Pump - H.P. <br /> r <br /> PUMP REPLACEMENT: / / State Work Done. <br /> PUMP REPAIR: / / State Work Done <br /> J)ESTRUCTION OF-WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 of: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 TITLE �/hf rilGif <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -9 <br /> APPLICATION'ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE Z W INSPECTION BY DATE -7 <br /> CALL FOR A GROUT .INSPECTION PRIOR .TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7172 lM <br />