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F 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. �r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In <br /> In Triplicate) <br />= Application is hereby made to the. San: Joaquin Local Health District for a p r it `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 /> I&_0S,0 � - -,4 Fid_.1,0VX 4 1 r <br /> JOB ADDRESS/LOCATION ' ��a �Lta, Udf 4-101 Q4- rl 4t . CENSUS TRACT <br /> Owner r s Name . `, C�-co e4] d 7' �e <br /> &66 <br /> r'lla Phone <br /> Address (j. 1 b <br /> City 47v U � - <br /> Contractor's Name t License # Phone <br /> { <br /> �� O 74 74 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN"/—/ 'RECONDITION DESTRUCTION /? <br /> _ i <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION.-.SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation r <br /> Domestic/private Drilled Dia, of Well Casing �• <br /> Domestic/public Driven ' Gauge of Casing ; <br /> Irrigation <br /> g Gravel Pack Depth of Grout Seal � a <br /> Other Rotary Type of Grout <br /> Other <br /> Other Information i f <br /> PUMP INSTALLATION ' �`Contractor � <br /> Type of PumpIr <br /> H.P. SM <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: j�%T State Work-'Done <br /> JD <br /> ESTRUCTION 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 1 <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 /> in€ormationwis true to the best of my knowledge.Ma belief. <br /> SIGNED ` <br /> ITLE �.. <br /> ( PLOT LAN ON RE RSE SiDE�_ <br /> FSR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA_S I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7172 1M � <br />