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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL. --OFF10E USE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> W Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;�3_ 33 4f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued G f 3 <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 ,Ztp ,S S�� �• ib�ucl T � � CENSUS TRACT <br /> Owner's Name6 7� G.r- Phone <br /> Address ��� � - City <br /> Contractors Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN/ / RECONDITION_/ / DESTRUCTION /_7AL <br /> PUMP INSTLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> Ih DISTANCE TO NEAREST: SEPTIC TA14KSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS-_- <br />{ Industrial Cable Tool Dia. of Well Excavation _ <br /> _ 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 /> PUMP INSTALLATION: Contractor <br /> 7 o,27f <br /> Type of Pump i11 H.P. <br /> PUMP REPLACEMENT: j / State Work Done <br /> t -- <br />'{ PUMP 'tEPAIR: / / State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br />•, Describe Material and Procedure <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 before putting the well in use. The above <br /> ji information is true to the best of my knowledge and belief. <br /> z <br /> 'i SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ACCEPTED BY �' DATE Cy AS- <br /> APPLICATION � <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION PISA ]JI/Fl,,NAL INSPECTIQN <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC . <br />