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'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave'. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J3-�L/Elo <br /> THIS PERMIT EXPIRES 1- YEAR FROM DATE ISSUED Date Issueds <br /> (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 S CENSUS TRACT <br /> F - <br /> Owner's Name I, Phone <br /> Address L ' fi City <br /> Contractor's Name License. #lk2 Phone <br /> TYPE OF WORK'(Check): NEW •WELL '/---/' DEEPEN-/7—z RECONDITION.J-7 - DESTRUCTION ./ . <br /> PUMP INSTALLATION / / PUMP REPAIR /9/ ' PUMP REPLACEMENT /_7 ! <br /> Other <br /> 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL ,, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia: of Well Excavation Is,,; <br /> Domestic/private Drilled Dia3 of Well 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 /> PUMP INSTALLATION: Contractor <br /> ` Type of Pump H.P. <br /> { <br /> k <br /> FUME' REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: `�`' <br /> _ 40�71_ State Work Done <br /> ESTRUCTION OF WELL: Well Diameter � Approximate Depth ► <br /> Describe Material and Procedure +, I <br /> i <br /> , I <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 beforeputting the well in use. The above <br /> information is true to the best of my knowledge and belie€. <br /> SIGNED A L TITLE E <br /> (DRAW PLOT P ON REVERSE SIDE <br /> PHASE I �— <br /> FOR DEPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED BY 4 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I I FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR.A;GROUT INSPECTION PRIOR TO GROUTING AND INSPECT oo <br /> ON. ` <br /> E H 1426 , . r,. 7 <br /> F� /72 lM <br />