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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. O1-FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r + �3 <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 /> CENSUS TRACT <br /> ,FOB ADDRESS/LOCATION <br /> Owner's Name Phone F&S P1.7 <br /> Address S 3-2— City Y <br /> Contractor's Name £ License S5l2�Phone S� -S/ID <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN !_1 RECONDITION /% DESTRUCTION /r7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> j INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />€ Industrial Cable Tool Dia. of Well Excavation <br /> i Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor fg�-4 <br />} Type of Pump v b H.P. <br /> F <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: State Work Done)&:bJ 16y:"MA kr�� <br /> } ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> { I hereby agree to comply with all laws and regulations of the Sail Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of any 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 he est of y knowledge and_belief. 0� _ M ��o <br /> CJeL. <br /> `i SIGNED TITLE <br /> .fr V (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> i <br /> PHASE i DATE <br /> APPLICATION ACCEPTED B - <br /> ADDITIONAL =D=ENTS: <br /> PHASE II GROUT INSPECTION PHASE I•I NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.` $ <br /> E H 1426 - 5/731M <br />