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OYU LX <br /> i <br /> SAN ,JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf. OFFICE USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> :APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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, 1 <br /> JOB ADDRESS/LOCATION �� �i � - CENSUS TRACT <br /> Owner's Name .� Phone —;?23 -61 __ a <br /> Address C�� `� L 0 City E.f <br /> Contractor's Name -Y License 4� Z Phone -�/�`�f' <br /> TYPE OF WORK (Check) *. NEIL WELL DEEPEN / / RECONDITION / / /DESTRUCTION <br /> PUMP MP INSTALLATION / PUREPAIR / PUMP REPLACEME N_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TAiINK 5 SEWER' LAVES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITO, OTHER S� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION `SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 0" <br /> Domestic/private. Drilled � ---Dia-:- of-Well Casing- 1/ t <br /> Domestic/public `� Driven Gauge of Casing- . <br /> Irrigation� �`. Gravel Pack I�`. 'Depth of Grout Seal 717 1 ° <br /> Other _ Rotary Type of Grout <br /> 4 Other ?_ '4' Other Information �l / - J raclg_Lj <br /> PUMP INSTALLATION: Contractor <br /> Type%a Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP `tEPAIR: '�/ State Work Done <br /> Q <br /> DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> j <br /> Describe' Material and Procedure' <br /> I hereby agree to comply with all Jaws 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`lt.i e,�to the best of my knowledge and belief. <br /> SIGNED .!LL TITLE Lei <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> ' APPLICATION ACCEPTED BY DAT f <br /> ADDITIONAL CONIMNTS: .�4" .,. , .t„ r f. AP.&W. q . <br /> PHASE II GROUT INSPECTION PHA E II FINAL INSPECTI N <br /> INSPECTION BY DATE 4 ngO-7;Z INSPECTION BYDATE L <br /> t CALL FOR A GRO INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> 5/.7 31x2 <br />