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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton'Ave. , Stockton, Calif_ . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.X02_ 7f 4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicatl:on 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 ADDP�ESS/LOCATION ,S CENSUS TRACT <br /> Owner'a rdame ff I3, � ,1�, ,_ t _ _ Phone 4 <br /> L2_,Wi 7A <br /> Address _ City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD�p�A CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 1677 <br /> Doaestic/privateDrilled Dia, of Well Casing11 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal zo Ir <br /> Other (` Rotary Type of Grout I rp-� <br /> Other Other Information - _— <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUNT REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter y Approximate Depth --- <br /> Describe Materia. 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 G TITLE �r p <br /> (DRAW PLOrT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �. DATE f O l d 17 2__ <br /> ADDITIONAL COM <br /> GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �3ATE <br /> Io 7� -e <br /> CALL FOC A GROUT INSKjE�TION�PR O TO OUTI AND FINAL INSPECTIO6. <br /> E H 1425 was- f1<y ' �2 � �. T/72 1M <br /> c .�� /n�� �� •.. �'-'.;-fir�- <br />