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' SAN JOAQUIN LOCAs, HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �. i Telephone:p (209) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> TRIS PERMIT EXPIRES 1 YEAR FROM DATE"ISSUED ..Date Issued , k <br /> (Complete In Triplicate) ,,, } <br /> Application is .hereby made talthe San Joaquin Local Health District for: a permit to construct <br /> and/or install the work herein described. This application i.s made in compliance with' San Joaquin <br /> County Ordinance No. 1862 and4the Rules and Regulations of the San,Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION j 2 Z € /1JjR p <br /> CENSUS TRACT <br /> Owner's Nam r = C D y <br /> —IC f�-�.[A� _�.�1�,. Phone <br /> Address / z z. l fw,me o <br /> City. _S le/V <br /> Contractor's Name License # j Phone ` <br /> } <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN / RECONDITION /� DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /3�T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Z <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED. USE TYPE OF WELLs <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable. Tool Dia. of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public ? Driven Gauge of Casing <br /> Irrigation ! Gravel Pack Depth of Grout Seal <br /> , Other I Rotary Type of Grout <br /> I Other Other Information <br /> PUMP INSTALLATION Contractor V: <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> { <br /> PUMP REPAIR: / / State Work Done <br /> } <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 <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 Distriet 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 /> SIGNED �Lttr�GtiZctaTLE <br /> (DRAW PLOT P ON REVERSE SIDE) - _ z <br /> t <br /> FOR DEPARTMENT USE ONLY # <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHAS III SINAL INSPECTI0 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL, FOR A GROUT_INSPECTION PRIOR TO..GROUTING AND FINAL INSPEC ON. <br />