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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS'.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephoner (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �i�_ �J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 300,-6,0 <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 Disgrict. <br /> JOB ADDRESS/LOCATION �.�7 '�I` �- yd iJ" g/ CENSUS TRACT E <br /> Owner's Na) 09 S <br /> A, <br /> Address C ity <br /> Contracto �s 'NameLicense #ggz <br /> .� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTAL ION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSA�IogIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS J <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private 4_ Drilled Dia. of Well Casing bF <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Other '"" "" "" Rotary - - - Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump7 H.P. <br /> PUMP REPLACEMENT: / / State 'Work Done <br /> 'er <br />-�P_UMPL;-REPAI-R:_ State t-Work=Done,T--"_ - - -_ - — <br /> .DFCTRUCTION OF WELL: Well Diameter* Approximate Depth. <br /> Describe Material 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 /> SIGNEDx.� M• C�n.w (L.�hW. j TITLE <br /> ��DRAWPLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ': APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P INA9 INSPECTI N <br /> INSPECTION BY DATE _ T INSPECTION B DATE` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN ETI <br /> E H 1426 5C731M <br />