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SAN JOAQUIN LOCAL HEA14TH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton- Ave. , Stockton, Calif. <br /> Telephone: ;(209) '466-6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�5 6 <br /> THIS PERMIT EXPIRES 1 YEAR -FROM DATE 'ISSUED.- Date Issued <br /> . yr <br /> .. ...(Complete In Triplicate) <br /> Application is hereby inade: to ;the San-, Joaquin Laca1 Health -District for a permit to construct <br /> and/or install the work herein described. This application is made 'incompliance with San Joaquin <br />-County Ordinance No. 1862 .andlthe Rules and Regulations of `the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S/ 1 m I B�c ,. CENSUS TRACT 'S+7 <br /> Owner's°,Nazne Y:� . 'r Phone <br /> Address Sao - City <br /> ._ a License ��1-7/�o r) Phone <br /> Contractor's Name <br /> TYPE OF W' . (Check) : NEW WELL '/ DEEPEN / / RECONDITION /� DESTRUCTION /? <br /> PUMP INSTALLATION / I PUMP REPAIR / PUMP REPLACEMENT I�T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> � l <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrialable Tool Dia. of Well Excavation p <br /> >` Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing {� <br /> VIrrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout A <br /> Other Other Information t <br /> PUMP INSTALLATION: Contractor <br /> I Type of Pump H.P. <br /> t PUN P REPLACEMENT: / I State Work Done <br /> PUMP REPAIR: O State Work Daae <br /> r.1111STRUMON—OF`WELL:"—`W61:r-Dia eter <br /> ^�� A roximate De th � <br /> Describe Material and Procedure <br /> F 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 a d belief. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /3� Y <br /> ADDITIONAL COMMENTS: s )' PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY pr DATE _ -- INSPECTION <br /> {, CALL FOR A GROUT INSPECTION PRIO-R. TO GROUTING AND FINAL INSPECTION. 4172 <br /> E H 1426 <br />