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i <br /> 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 <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. 1862 and_ the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION& _ -r.> z-roc . ¢ € �14-w�-C.A; CENSUS TRACT © - 7-4o-97g <br /> - k}} <br /> Owner's Name !1 Phone t7 <br /> Address Citya �. <br /> i - -- - -- — <br /> Contractor's Name License IVB, Phone,3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION & PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTICTANKSEWER LINES -- PIT PRIVY \3 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �1 <br /> -_ Industrial 1 j[ Cable Tool Dia, of Well Excavation / <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public Driven _ - Gauge of Casing <br /> ­%__ Irrigation_. A Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> ! � r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> f � <br /> k <br /> PUMP REPLACEMENT: / / State Work Done <br /> LPUWP REPAIRc State Work -Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> . <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 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 1-�:� ^TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> p FOR DEPARTMENT USE ONLY ' <br /> PHASE I \�_� � .: . <br /> APPLICATION ACCEPTED BY1tWAJ DATE -�$'r�. <br /> ADDITIONAL COMMENTS: E <br /> PHASEII GROUT INSPECTION PHASE III FINAL INSPECTION <br /> r INSPECTION BY=) &- DATE INSPECTION BY DATE <br /> CALL FOR 11 GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> h E H 1426 T/72 1M <br />