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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F07E"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 _7Lf <br /> (Complete In Triplicate) 2•OS- 2-to -l/ <br /> } Application is hereby wade 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 Saxe Jbaquix <br /> County Ordinance Na. T1862 and the Rules and Regulations of the San Joaquin Locaeal.th District. <br /> sAL /1 <br /> JOB ADDRESS/LOCATION � _.mi, 1 �2_a.,CA 0w,• s� „s�:. a ' CENSUS TRACT ' <br /> Owner's Name o Phone $ <br /> Address <br /> City • ��5�•�� <br /> Contractor's NAIne 91 <br /> License 4��a Phoned <br /> TYPE OF-WORK__(Check): NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /? <br /> E Other 1 <br /> DISTANCE TO NEAREST: SEPTIC TAi'NK SEWER LINES PIT PRIVY w' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITS �OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of.We'll Excavation <br /> Domestic/private Drilled Dia:'af Well Casing <br /> k Domestic/public Driven -Gauge of Casing <br /> Irrigation Gravel Packs s Depth of Grout Seal <br /> 4 Other . - `I2'otary ''r Type of Grout <br /> ,.Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP�`tEPAItt I:- - <br /> State Work Done , . <br /> DFfiTRUCTION OF WELL: Wel"i Diameter Y Approximate Depth <br /> - �•;G _ „Describe Material and Procedute <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 /> 1 r <br /> SIGNED `` TITLE <br /> ` (DRAW PLAT PLANION REVERSE SIDE) <br /> �. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY �2 <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE - IS/,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY L DATE - 27 -2 g <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING 'AND -1- NAL INSPECTION. <br /> ,_ ._ E H1426 5/731M <br />