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�! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> [OF. OF, ICb USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t! 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 .o£ the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ( G CENSUS TRACT <br /> � t �_, <br /> Owner's Name - yQ� Phone C7 <br /> Address 6 � ( <br /> City <br /> Contractor's name �.[ � cf License #& 1 phone <br /> TYPE OF WORK (Check) : NEW WELL '/ /, .DEEPEN /�% RECONDITION /_% DESTRUCTION /_ <br /> AL4 <br /> PUMP INSTLATION J PUMP REPAIR j5e_ PUMP REPLACEMENT <br /> Other`./­/ _n _ <br /> DISTANCE TO NEAREST: SEPTICiTANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL `r� CONSTRUCTION SPECIFICATIONS <br /> Industrial f= 't Cable Tool Dia.`�_of Well Excavation <br /> Domestic/private Drilled Dia"'oflWel.l Casing 3 <br /> Domestic/public, is,-, Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type,-of- Grout <br /> Other Other .Information <br /> ?UMP INSTALLATION: Contractor ts",t z- <br /> Type of Pump -Jt H.P. /Q <br /> PUMP REPLACEMENT: / / State Work Bone <br /> PUMP PAIR: �Y: State Work Done <br /> ,DFGTRUCTION OF WELL: Well Diameter l . _ — - Approximate Depth Q <br /> Describe Material and)Procedure <br /> i! N: <br /> I hereby agree to comply with all laws and ,tegulations of the San Joaquin Local Health District <br /> Gond 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 Heakth District <br /> BELL 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 /> �. <br /> SIGNED TITLE <br /> " DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE —oZ.�-7� <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION ° PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE - _ INSPECTION BY DATE -I j-,,7 4/ <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 1�/711m .� <br />