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G, 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. Z�1-_, z 4/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local Health District for a permit to construct <br /> and/or install theework 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 /> 30B ADDRESS/LOCATION S 3 w c4tn CENSUS TRACT <br /> Owner's Name i L Phone J,�� �'9a <br /> Address <br /> . h S��v C �!l�e City. <br /> License i� t� Phone <br /> Contractor's Name r3 a ' � . <br /> TYPE OF WORK (Check) : NEW WELL ,/ DEEPEN / / RECONDITION / / DESTRUCTION _� <br /> PUMP INST LLATION PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other F/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYP , OF WELL, CONSTRUCTION SPECIFICATIONS � <br /> Industrial & Cable Tool Dia. of Well Excavation tv <br /> Domestic/private Drilled Dia.. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal A72 `c <br /> Other Rotary -Type of Grout <br /> . . 1 Other Other Information <br /> ' 611d: N&IL&Aseof- <br /> 3 r <br /> PUMP INSTALLATION: Contrctor <br /> Type of Pump e — H.P. � -- <br /> � f <br /> PUMP REPLACEMENT: / / State Work Done .: <br /> PUMP 'tEPAIR: 4 "* / / -State Work DoneT'"'° - <br /> ,DF'ZTRUCTION OF WELL: Well Diameter s 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 an a new well, 'I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT_ o£ .the well. and notify them before putting the well in use. The above ; <br /> infor Yon 's true to the best of my knowledge and belief. <br /> { <br /> SIGNED TITLE <br /> (DRAW PLAT PLAN ON REVERSE SIDE) � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE APPLICATION ACCEPTED -BY r � DATE ,2 ~� ! ~/�- � <br /> ADDITIONAL COMNENTS: <br /> PHASE -Il GROUT IN PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE . 7 V INSPECTION BY A/J DATE -7 <br /> CALL .FOR A GROUT INSPECTIQN}PRIOR TO GROUTING AND FINAL INSPECTION. 5/731X <br /> �7� M <br /> - TT 11.nf' 7/I <br /> 31X <br />