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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POF.:OFFICE USE:. 1.601 E. Hazelton Ave. , ;Stockton, Calif. <br /> ' Telephone: (209} 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� aGrJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 2 <br /> k� (Complete In Triplicate.) / <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 District. <br /> JOB ADDRESS/LOCATION Y �,P CENSUS TRACT <br /> Owner's Name G iP- 1 Phone " <br /> Address City <br /> Contractor's Name Q /rte License #.2,9,, -75' Phone ' <br /> 7A30 . <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATIONw PUMP 'REPAIR / / PUMP REPLACEMENT /—T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ;CESSPOOL/SEEPAGE PIT OTHER' <br /> INTENDED USE ITYPE- OF WELL '+ ! CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ti" tDia. of Well Excavation <br /> i.. Domestic/private Drilled' _ ID`ia. of Well Casing <br /> F Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack !Depth of Grout Seal " <br /> Other : <br /> 3� l► Type of Grout <br /> .. Other ,;Other Information - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> f PUMP REPLACEMENT: 3 <br /> � / / State Work Done <br /> State W6rk Do-n <br /> ` DFGTRUCTION OF WELL: Well Diameter Approximate Depth f° <br /> Describe Material and Procedure <br /> A <br /> I 'hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californialpertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after compietion of my loon a new well, I will furnish the San Joaquin Local Health District a. <br /> WELL DRILLERS REPO R of the well and notify them before putting the well in use. The above <br /> information is r e tb the a_s-t o m�Swledge and belief. <br /> s SIGNED <br /> TITLE <br /> f (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I If <br /> APPLICATION ACCEPTED BY ;E DATE .S�o2 3 <br /> ADDITIONAL COMMENTS; �1 <br /> PHASE II GROUTiINSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY ;DATE .. .0 j INSPECTION BY &. DATE <br /> —CALL FOR-A-GROUT.-INSPECTION PRIOR.T0 ,GROUTING AND FINAL,INSPECTION. <br />