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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F dF.;OI 1 ICE USE: 1601 E. Hazelton °Ave. , Stockton, Calif. <br /> k Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zi- - 7 V i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z:2y Z,t <br /> (Complete In Triplicate) f <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 /> f <br /> 10 7,9,? <br /> JOB ADDRESS/LOCATION ;Gq l ®v` -` US,TRACT <br /> Owner's Name Phone <br /> 'k Address v <br /> 5 �. - city <br /> � f <br /> Contractor's Name s42zvls. License # Phone <br /> Cz <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN/ / RECONDITION /_/ DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR "/ / PUMP REPLACEMENT <br /> Other ';/-7 <br /> DISTANCE 'TO NEAREST: SEPTIC-TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> C1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool Dia. 'of Well Excavation_ �Q <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing -� <br /> Irrigation ! Gravel Pack Depth of. Grout Seal <br /> Other .1 Rotary Type of Grout <br /> f <br /> A Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACENfNT: / J State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter �� _ Approxi ate Depth j 3 � T <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 completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> IWELL 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 /> - f <br /> SIGNED TITLE <br /> (DECAW PrLOT PLAN ON 1KVVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> j APPLICATION ACCEPTED '.BY DATE <br /> ADDITIONAL COMMENTS., <br /> . <br /> PHASE I GROUT' INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE 1 -`J-7LI INSPECTION BY Q DATE <br /> F• CALL'F'OR A.GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 . . .. ._ 5/731M <br />