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r <br /> # ,w <br /> ` F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ► ,FOS',:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ► Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z S� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED gate Issued /1-F 7�J <br /> (Complete In Triplicate) <br /> k Application is hereby madeito 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 Ahd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 41n L l y, `t-�-� D _ CENSUS TRACT <br /> Owner's Name A R Phone <br /> ' City <br /> Address D LAJ <br /> Contractor's Name <br /> i r' , <br /> License # Phone`f�b —0691 <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT x / 7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS \ <br /> Industrial s Cable Tool Dia.- of Well-Excavation <br /> Domestic/private Drilled '`Dia,. of .'Wdl j, -Casing <br /> Domestic/public t Driven Gauge, of Casing Fx,.: <br /> Irrigation Gravel Pack Depth of G•roui' 'Seal, <br /> Other Rotary Type of Grout•'. F' <br /> Other Other Information <br /> r ' n <br /> PUMP INSTALLATION: Contractor <br /> Typ of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP TtEPAIR: ,� P / / State Work Done "y <br /> I3FSTRUCTION OF WET:L:, Well. Diameter Approximate Depth <br /> v Deser.ib.e„Materia_l ,and Procedure' - r <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 /> ager completion of my work on a new well., I will fur-dish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them beforle putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> .. _(DRAW_PLOT...PLAN-,ON REVERSE SIDE) <br /> 3 FOR DEPARTMENT USE ONLY , <br /> 4 <br /> 'PUASE I �, S <br /> APPLICATION ACCEPTED BY � L��X <br /> DATE ` ��� _ <br /> t' ADDITIONAL COiMENTS: 1 <br /> PHASE'PHASE 'ZI GROUT INSPECTION ----------PHASE /RIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �' -��-7S <br /> k CALLI F'OR-A GR T INSPECTION PRIOR TO..GROUTING .AND FINAL INSPECTION. <br /> 9 W 1A9A 5/731M <br />