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j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /x 1601 E. Hazelton Ave.. Stockton, Calif. <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONStRUCTION,OR PUMP PERMIT Permit No.,3_ <br /> s � <br /> THIS PERMIT- EXPIRES 1-YEAR FROM DATE ISSUED Date Issued/p.2��>�A .Y <br /> (Complete 'In Triplicate) <br /> Application is hereby�madevto .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 Joaquil, <br /> County Ordinance No;-1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F <br /> JOB FADDRESS/LOCATIONO �1S - {v4 CENSUS TRACT _ <br /> Owner's Name <br /> Phone ' <br /> E <br /> Address r - L G A City R A C w <br /> Contractor's Name '�L License 4i Phone <br /> S <br /> TYPE� OF WORK (Check) : NEW WELL ff DEEPEN/ / RECONDITION /'� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT /? <br /> Other. <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK p+ SEWER LINES — PTT .PRIVY <br /> SEWAGE DISPOSAL FIELD 2o' CESSPOOL/SEEPAGE PIT -- OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> M Industrial Cable Tool Dia, of Well Excavation Q <br /> Domestic/private Drilled Dia, of Weil Casing ; <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> ! Other Other Information �- <br /> h <br /> PUMP''�'INSTALLATION: Contractor 64 au D&LL <br /> _ Type of Pump U H.P. <br /> PUMP ,REPLACEMENT: J / State Work Done <br /> PUMP'•;REPAIR: / / State Work Done <br /> ,DESTRUCTIONOF WELL: Well Diameter Approximate Depth <br /> i 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 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 /> SIGNED-)e r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />,APPLICATION ACCEPTED BY DATE �� <br /> ADDITIONAL COMMENTS: wmz <br /> PHASE II GROUT INSPECTION P SEIII/FINAL INSPECTION All <br /> INSPECTION BY DATE INSPECTION BY DATE 4M-23 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEG ON. _ <br /> ElH 1426 4172 3M <br /> y -� •� <br />