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[bio. <br />' �• l� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rF-O1.,OFFICL USE: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br />{ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f (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 Sart Joaquin <br /> County Ordinance -No. 1862 atd the Rules and Regulations of the San Joaquin Local Health District. <br /> r <br /> 2--o g--o 4.0-- 13 <br /> JOB ADDRESS/LOCATION: /4"E (,cJ e N �O- JXAFCENSUS TRACT <br /> Owner's Name Phone ' <br /> Address .Z / City <br /> Contractor's Name License Phone ' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/,-/ RECONDITION %/` DESTRUCTION /- <br /> PUMP INSTALLATION _/ PUMP REPAIR / / PUMP REP CEME T /� ~ <br /> other 1 / C u r7`b c tLG <br /> j, _.,_... <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER fh <br /> l . <br /> INTENDED USE TYPE OF 14ELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia.. of Well Excavation <br /> :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 /> PUMP INSTALLATION: Contractor <br /> Type lof Pump H.P. /� p <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br />'nom PUMP 'REPAIR: /�PAState=Work=Done L <br /> ij DFCTRUCTION OF WELL: WellDiameter Approximate Depth <br /> Describe Material aftd 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 weli,ii will furnish the San Joaquin Local Health District a ; <br /> WELL DRILLERS REPORT of thewell and notify them before putting the well in use. The above <br />'# information is true to t best of my knowledge and belief. <br /> 1 f t <br /> SIGNED. - TITLE c_ ,--, <br /> t i (DRAW PLOT PLAN ON REVERSE SIDE <br /> - - FOR DEPARTMENT USE ONLY - <br /> PRASE 1 <br /> E APPLICATION ACCEPTED BY DATE <br /> j ADDITIONAL COMMENTS: t � <br /> PHASE II GROUT, iINSPECTIO P I/FINAL INSPECTIN <br /> INSPECTION BY INSPECTION SY DATE 6134 <br /> 1 - CALL_I'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP TION. <br /> E H 1426 C: /7 Z to 62" <br />