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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> v0£. OFFICE USE:: 4 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> ii THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 7 <br /> ii <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT 'u U 0 �v� 'E ar ' <br /> Phone <br /> Owner's Name . v <br /> ,_L� it ✓'� S ! 0 0 5 City <br /> Address ' <br /> ;I L�/_ License # 1�eZ Phone '50K.2-6"7 <br /> Contractor's Name � : % �Z - 0 ---- <br /> ;i <br /> I TYPE OF WORK (Check) : I�NEGI WELL DEEPEN '/ / RECONDITION / / DESTRUCTION 1-7 <br /> 11 PUMP INSTALLATION / / P:6W REPAIR PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f <br /> 4 `SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (), <br />{h <br /> INTENDED USE �� TYPE OF WELL CONSTRUCTION SPECIFICATIONS U <br /> I Dia. of Well Excavation <br /> ,, Cable Tool <br /> industrial <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publicil Driven Gauge of Casing r <br /> C �r � Irrigation ip Gravel Pack Depth of Grout Seal <br /> Other iM Rotary Type of Grout <br /> Other Other Information <br /> E <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ` / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> DFCTRUCTION OF WELL: �j Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> h <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 'construttion. 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 /> informati s true io the best of m knowledge and belief. <br /> !I <br /> TITLE 0— <br /> SIGNED ' / <br /> (DRAW PLOT PLAN ON REVERSE Si <br /> �; II FOR DEPARTMENT USE ONLY <br /> i. . <br /> PHASE I DATE <br /> APPLICATION ACCEPTED11BY <br /> ADDITIONAL COMMENTS: IE <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY ii DATE INSPECTION BY DATE <br /> .-CALL.-FOR. •GROUT-TNSPECTION-PRIOR-TO. GROUTING .AND FINAL..INSPE ON. 7 1 G <br /> F u ZG�F, <br />