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F 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� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -S 7 - <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaq"ilin 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 thees and Regulations of the San Joaquin Local Health District. <br /> rt Pf <br /> JOB ADDRESS/LOCATION 417 CENSUS TRACT <br /> Owner's Name `# Phoned 3-•,�'' '~ <br /> Address I y City <br /> Contractor's Name License #,M&&1,,,1& Phone f�>q <br /> TYPE OF�WORK (Check) : ' NEW WELL / / DEEPEN /_/ RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> E Otherl/ / <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGEEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> F Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other _ Other Information (J. <br /> PUNA' INSTALLATION: Contractor <br /> Type f Pump H.P. / <br /> PUMP REPLACEMENT: /tate Work .Done <br /> _ i <br /> PUMP REPAIR: / / State Work Done <br /> pESTRUCTION 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 regulatin well construction. Within FIFTEEN DAYS <br /> after completion of my work oin a new well, I will fd2sh 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 est of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE _ <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTIO 4W7ECTIO5N <br /> CALL FOR A GROU INSPECTION PRIOR TO GROUTING AND FINAL <br /> EH 1426 X73 <br /> k � # <br />