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Gf <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br />€ For.�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 1y-8':7sG <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 an"eaulatia of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION hdlca� r�c.�• �Z` - "CENSUS TRACT ,-2// , <br /> Owner's Name , �l�c�-l''�-� Phone 1/1,(- 5, 3 SJ <br /> Address 20 3 O City S LKAI <br /> -- <br /> Im Contractor's Name f / � _ License #:Z6 S-761% Phone.4E 0-r9_3_2 <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK Wd SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> x.111 <br /> INTENDED USE TYPE..OF WELL CONSTRUCTION SPECIFICATIONS <br /> s Industrial _ Cable Tool Dia. of Well Excavation <br /> _ Domestic/private. n Drilled Dia. of Well Casing v <br /> Domestic/public ! Driven Gauge of Casing <br /> Irrigation iGravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> e <br /> PUMP INSTALLATION: Contractor <br /> E Type of Pump �� Hop. <br /> d <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 't2PAIR: / / State Work Done <br /> ,DF'sTRUCTION 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 knowledge and belief. <br /> l <br /> SIGNED TITLE <br /> (DRAW PLOT AN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> s PHASE I <br /> APPLICATION ACCEPTED..B DATE r <br /> { ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE . IF;NW I38PECTI <br /> INSPECTION BY DATE INSPECTION BY / ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TOm GROUTING AND FINAL INSPECTZ <br /> .. E H 1426 _5/731M <br />