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SAN JOAQUIN LOCAL II�sALTF? DISTRICT <br /> FOR OFFICE USE:T 1601 E. Hazelton :Aver. Stockton, Calif. ' <br /> Telephoner (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED , Date Issued 7 y <br /> (Complete. In Triplicate) <br /> Application is here 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 J' <br /> County Ordinance No. 1862 and" the Rules and Regulations of the San Joaquin Local Health District. f; <br /> A . } <br /> .TOB ADDRESS/LOCATION 1/ �1' ( q��'� ��ggj' � � CENSUS TRACT � <br /> Owner's Name /�, /� �l S - - - - - -- Phone�OJ ol! <br /> Address p� /� City <br /> Contractor`s Name ! _1/ �2 License IV n p .Z <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ / RECONDITION /_� DESTRUCTION /? E' <br /> PUMP INSTALLATION J / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK,,-5SEWER LINES PIT PRIVY r- <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE 5FWELL CONSTRUCTION SPECIFICATIONS <br /> idustrialn1 Cable Tool Dia. of Well Excavation <br /> omestic/private. t Drilled Dia. of Well Casing s <br /> Domestic/public '! Driven Gauge of Casing / <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout qyae-4 zey s <br /> I Other Other Information" <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / 5 ate Work Done <br /> PUMP REPAIR: / / Sate Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> I hereby agree to comply withfall laws and regulations of the San Joaquin Local Health District r <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 st of my nowledge and belief. <br /> SIGNED TITLE .� <br /> >1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I <br /> APPLICATION ACCEPTED BY /(_`% DATE <br /> ADDITIONAL COMMENTS: " I <br /> PHAS II GROUT INSPECTION, PHAS III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE j <br /> CALL FOR A GR T INSPECTION PRIOR TO GROUTING AND FINALJ;NSPECT <br /> E H 1426 T c,►e.��aY,a- �.. 3s „ � .s yr 4172 IM <br />