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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For. 011' cq USI.: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELT. CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued R-i L13 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/orinstall 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 yDistri.ct. <br /> -/43' g �. - k . 0 2- / 02-0 -S 4 7 <br /> JOE ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name . Phone 7,,2-7 y <br /> Address L: J+\ V �4�- a�oy c <br /> Contractor's Name License #/Y37L Phone7Vz <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN / J RECONDITION / / DESTRUCTION /_ � <br /> PUMP INSTALLATION / / PLW REPAIR /—/ PUMP REPLACEMENTI-7 Vv <br /> Other / / — --- <br /> DISTANCE TO NEAREST: SEPTIC TANK�, ( SEWER LINES PIT PRIVY fit <br /> SEWAGE DISP SkT AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial /---Cable Tool Dia. of Well Excavation 141 <br /> t_,�mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ <br /> Irrigation Gravel Pack Depth of Grout Seal .S-0 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -q.EPAIR: / J State Work Done r <br /> ,DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 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 /> SIGNED r� _ ! _ TITLE <br /> - (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 4 <br /> APPLICATION ACCEPTED BY41- <br /> DATE <br /> - - -- -- - - <br /> ADDITIONAL COMMENTS: - - - <br /> PHASE W GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ?-./y INSPECTION EY1�✓ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ] <br /> E "r! 1426 5/731M- <br />