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SAN JOA UIN LOCAL <br /> 4 HEALTH DISTRICT <br /> f`o .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .&--.34-� <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. 186.2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 2n P7? Phone 3 7j_7 2 <br /> Address City . <br /> Contractor's Name License #oV/�j� Phone <br /> TYPE OF WORK (Check) : NEW WELL / /ALDEEPEN / 1-7_/ RECONDITION /_% DESTRUCTION / <br />` PUMP INSTLATION / / PLW REPAIR / / PUMP REPLACEMENT IZ: ' <br /> Other ./ <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 Tf <br /> Industrial Cable Tool Dia., of Well Excavation �; <br /> _Domestic/privateDrilled 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 /> PUMP INSTALLATION: Contractor" g <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /State Work Done [?CI v2fJ� cI <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DF�TRUCTION 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, be t my knowledge and belief. <br /> SIGNED '+ <br /> TITLE � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY <br /> T DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION II / �ALN�SECT�10NINSPECTION BY DATE INSP I2 � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />