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r <br /> r <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT A(� <br /> FOF.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. d� <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7 7-190 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE :ISSUED Date Issued���' <br /> ('Complete In Triplicate) <br /> Application is hereby made �o 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 acid the Rules and Regulations of the San Joaquin Local Health District. <br />' JOB ADDRESS/LOCATION � l3Do S: — -� <br /> �_✓��.E� ��„ „ CENSUS TRACT 5.5'-Zoo-YS <br /> I Owner's Name ^..� � � - - . . ..,..._ Phone < �7 8t3 . <br /> Address City <br /> Contractor's Name C' License ��/ �rs�,Phone <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPENN . I RECONDITION / / DESTRUCTION fes" <br /> PUMPINSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK,,, SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> � fns <br /> INTENDED USE 1TYPE OF WELL CONSTRUCTION SPECIFICATIONS p <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 i Gravel Pack Depth of Grout Seal <br />` Other # Rotary Type of Grout <br /> Other Other Information <br /> r <br /> f PUMP INSTALLATION: Contractor � i <br /> - - -- <br /> Type of Pump - 1,�.� _ H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP T2EPATR: / / State Work Done <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> i 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 /> i WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true o the best f my knowledge and belief. <br />'r SIGNED TITLE �.� rn c J o <br />'s (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> i APPLICATION ACCEPTED BY DATE�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III • INAL INSPECTION, <br /> INSPECTION BY 'DATE P , :,,,INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 K/71im <br />