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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I'OF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g� 76 <br /> (Complete In Triplicate) ti <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 3Z. A _ t CENSUS TRACT <br /> Owner's Name — Phone -,962 •- L672 <br /> Address _,Z_�_ _ CjZ,e�-Q _ •� City <br /> License <br /> Contractor's Name ��Zpp Phone <br /> d-DrvQ6 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENt/- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK p SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Lf <br /> Domestic/public Driven Gauge of Casing 1 too PVC \} Y <br /> Irrigation Gravel. Pack' , Depth of Grout Seal <br /> Other Rotary Type of Grout 4 r <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DF',TRUCTION OF WELL: Well. Diameter Cf Approximate Depth <br /> Describe Mater al 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 /> 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 /> r r <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN6PeCTION. <br /> E H 1426 5/731M <br />