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V? SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> o .�oi'r,iCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'��G(J <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued -) <br /> 41 (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to const::uct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance -No. 1862 a _ id Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI CENSUS TRACT <br /> Owner's Name fi o A-L le Phone <br /> Address _ __-.K- . .. City <br /> Contractor's Name C 7's6s' License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /P�'DEEPEN / / RECONDITION /—/ DESTRUCTION /`7 <br /> PUMP AL <br /> INSTLATION / / PLW REPAIR '/—/—PUMP REPLACEMENT /-7 <br /> Other I I G c� �' �► k., 4 (--Y k"9-1- <br /> DISTANCE <br /> "9-LDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> J <br /> INTENDED USE ;TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> L---Industrial t Cable Tool Dia. of Well Excavation \ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation «1 Gravel Pack Depth of Grout Seal <br /> Other It Rotary Type of Grout <br /> J, Other Other Information, <br /> 1 <br /> PUMP INSTALLATION: � <br /> Conti ctor <br /> Type of Pump Le H,p. <br /> PUMP REPLACEMENT: / / ' State Work Done � Al wr �A 4 L AZ 6 <br /> PUMP 'tEPAIR: �/ / �tate -&lark Done <br /> I <br /> ,DFgTRUCTION OF WELL: Well'' Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> l <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 TITLE <br /> t 1 (DRAW PLOT PLAN ON REVERSE SIDEI <br /> # FOR DEPARTMENT USE ONLY <br /> k PHASE I <br /> .APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA /FINAL INSPECTION , <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -CALL,FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. <br /> E H 1426 E�/7'41m <br />