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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a_ io . OI'IICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. v <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 1 y� <br /> -- -4 <br /> t� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-1s=_;�� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> find/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 / V E Q ty CENSUS TRACT <br /> Owner's Name /, T:) �' N to fl �' (��• 14 i!alb Phone <br /> Address a q City �CA..- <br /> .01 <br /> Contractor's Name c� ' License # / `Phone 7 <br /> 474 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/% RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION J / PUMP REPAIR / PUMP REPLACEMENT <br /> Other /_/ — <br /> DISTANCE TO NEAREST: SEPTIC TA;vK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTI3NDEI) USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. 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 /> Pbi�;P INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. l Y <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: &I State Work Done ` <br /> DFgTRUCTION 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 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 knowl&d'ge- nd belief. <br /> SIGNED <br /> +�� TITLE r' <br /> W LAN ON ERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APrLICATION ACCEPTED BY v✓ ,u`vy'�'.� DATE <br /> ADDITIONAL C0 uIENTS: <br /> PHASE II GROUT INSPECTIONP I NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ON. <br /> E H 1426 r /r __ <br />