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(/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOF. OFFICE USE: 1603. E. Hazelton Ave. , Stockton, Calif. <br /> F- �I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nn- ,Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7---ZL( <br /> (Complete In Triplicate) ermit to ,const�uct <br /> ic <br /> Applation is hereby ma to the San Joaquin Local Health District for a p <br /> and/oris install the work herein described. is made in compliance with San Joaquin <br /> This application <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> l� CENSUS TRACT . <br /> JOB ADDRESS/LOCATION __Lap CJ _ _ <br /> Phone ��F-d �S / <br /> Owner's Name <br /> City <br /> Address <br /> i License # L 02 Phone -A �� <br /> Contractor's Name ' <br /> TYPE OF WORK <br /> Check ): NEW WELL I DEEPEN / / RECONDITION_/ / DESTRUCTION /�T <br /> PUMP <br /> � INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT / <br /> ` 0th' ./k/ O <br /> k DISTANCE TO NEAREST: SEPTIC TkNK SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE _ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing � 2 �?�l <br /> Domestic/private � <br /> 14 zz <br /> Domestic/public Driven Gauge of Casing C�_ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of gout <br /> T Other Other Information ' <br /> E <br /> PUMP INSTALLATION: Contractor H.P. , <br /> "Type of Pump — <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: ~ /{ State Work Done <br /> i Approximate Depth <br /> UF�TRUCTION OF WELLc Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> t 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 <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 be <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I .� . �Q�1�0'E{ DATE 712- y <br /> ;, APPLICATION ACCEPTED .BY <br /> j' ADDITIONAL COMMENTS: PSE I FINAL INSPECTI N <br /> r PRASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> ; CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON. <br /> 5/731M <br /> — , i n r_ - - - -- <br />