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r' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � 7� � 1-1-2 <br /> APPLICATION <br /> Telephone: (209) 466-6781 7`f �. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. — <br /> i _ <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 work3herein described. ' This application is made in compliance with San Joaquin <br /> and Regulations of the San Joaquin Local Health District. jj <br /> County Ordinance No. 18G2 and the Rules <br /> � CENSUS � . <br /> JOB ADDRESS/LOCATION v A V aJA d TRACT... <br /> Phone 46;3 <br /> Owner's Name w/VCO MN Gh./!r!t OROS <br /> Address nod I �U 1� U City 9 'Th"Al /f��l� <br /> License #7jj L - Phone !r f' <br /> Contractor's Name •••�`" <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / I DESTRUCTION /_7 <br /> i PUMP INSTALLATION / / PUMP REPAIR Y/ PUMP REPLACEMENT I_7 <br /> Other <br /> DISTANCE TO NEAREST: (SEPTIC T&RK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER' <br /> IM <br /> INTENDED OF WELL CONSTRUCTION SPECIFICATIONS <br /> ED USE i T <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 a Depth of Grout Seal <br /> Other .'V IL Rotary " Type of Grout <br /> iM Other t Other Information <br /> .iM <br /> - - <br /> PL',MP INSTALLATION: Contractor <br /> l Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR:- State Work Done 7yi,11' <br /> s <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 eompL'etion of my work on a new well, I will _furnish the San Joaquin Loea Health District ;a <br /> S WELL DRILLERS REPORT bf the well and notify them before putting the well in use. The above <br /> information as true to the best of my knowledge and belief. ] <br /> d <br /> SIGNED TITLE _ <br /> � r <br /> (DRAW P PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I DATE %l <br /> APPLICATION ACCEPTED BY tom✓ i <br /> " ADDITIONAL CO101ENTS: � PHASE (FIN INSPECTION �l <br /> PHASE II GROUT INSPECTION , PATE�jZ 3 <br /> INSPECTION BY DATE INSPECTION B <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> I5/731M <br /> p <br />