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� � V <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 'OF.;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,,] <br /> THIS' PERMIT4EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued �� <br /> (Complete In Triplicate) t,6 L{ - ((ob -gf <br /> Application is hereby made to the San Joaquin Local Health District for a permit to .const uctl <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 /> JOB ADDRESS/LOCATION WGA CENSUS TRACT <br /> Owner's Name Phone <br /> Address';:.-�.:_�• ..:��-:/»_ ��. . ,�. -.,.. �. - <br /> 'AV City _ <br /> Contractor's Name oe� License # Phone <br /> TYPE OF WORK (Check)t ­NEW WELL / / DEEPEN _% RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR -/ / PUMP REPLACEMENT (7 <br /> Other ./ <br /> DISTANCE TO NEAREST: SEPTIC11TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia: of Well Excavation <br /> _ Domestic/private Drilled 1 Dia. of Well Casing- <br /> Domestic/public Driven Gauge 'of Casing v <br /> Irrigation t Gravel Pack' Depth of Grout Seal <br /> Other . Rotary Type. of Grout <br /> Other ,,Other'Information <br /> tjy <br /> PUMP INSTALLATION: Contractor l.)¢ <br /> Type of ,Pump <br /> R.P. �. <br /> PUMP REPLACEMENT: / j State Work Done 4 <br /> PUMP J1(J State Work Done , . <br /> .DFCTRUCTIOI4 OF WELL: Well' Diameter Approximate Depth �^ <br /> Describe Material and Procedure. <br /> I hereby agree to'comply with all laws and` regulatibns of the San Joaquin Local Health District <br /> and the Stag 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 <br /> 149LL DRILLERS REPORT of the swell and notify them before putting the well in use. The above al <br /> information is true•-to the best f k wlede�aud belief. <br /> SIGNED <br /> +� ✓ TLE <br /> DRAW .PLOT, PLA�ON_R -RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � � J DATE 7� <br /> ADDITIONAL COMMENTS: 1 E <br /> PRASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7,61 r' <br /> • <br /> CALL .FOR-A GROUT-INSPECTION PRIOR TO GROUTING-AND-FINAL INSPECTION. <br /> E H 1426 <br />