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r; I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F.-"01T10E USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT- Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued =15— <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 /> Cou ty O inancq No. 182 and he Rules and Regulations of the San Joaquin Local Health District. <br /> JO ADDRESS/LOCATION CENSUS TRACT . <br /> Owner's Name <br /> Phone <br /> Address 4 A� � �a 71 .._ City G1' eXj <br /> Contractor's Name , License ��®2o0`7g Phone f <br /> TYPE.OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION/_/ DESTRUCTION /_7 <br /> PUMP INSTAL ATION � /PUMP REPAIR / PUMP REPLACEMENT /7 <br /> y Other /% — — <br /> DISTANCE TO NEAREST. S%PTICTANK —�_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �. CESSPOOL/SEEPAGE PIT OTHER <br /> INT9IMED 'U5E TYPE OF WELL CONSTRUCTION SPECIFICATIONS J <br /> Industrial Cable Tool –Dia. of Well Excavation01 <br /> _ Domestic/private a Drilled Dia. of Well Casing <br /> Domestic/public Driven 'Gauge of-Casing <br /> Irrlgatioii�;`, { Gravel Pack Depth of Grout Seal -Z� -7/ � <br /> Other1 �G Rotary . - Type of Grout <br /> r" Other Other Information <br /> PUMP INSTALLATION:` i ,..: <br /> s COntraCtor <br /> Type of Pump <br /> PUMP Ri,PLACEMENT: / / State Work Done <br /> PUMP U-PAIR: _ - <br /> State Work Done <br /> t - <br /> ,DFGTRUCTION OF WELL: -Weil biameter. Approximate Depth <br /> Describe,­Material and Procedure. <br /> I hereby agree to comply with all laws and regulations of the Sari Joaquin Local Health. District <br /> and the State of California pertaining to or regulating r,,cell "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 /> informatio s rue to the best. of m owledge and. belief. <br /> SIGNED GV. TITLE Qes f �� <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY "YS DATE <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTIONPHASE III/F NAL INSPECTION ` <br /> INSPECTION BY DATE . 2 - INSPECTION BY � DATE <br /> CALL FOR A GROUT INSPECTION PRIOR .TO GROUTING AND FINAL, INSPECTION. <br /> E_4 14.26 <br /> 5/.7 3-IM <br />