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SAN JOAQUIN LOCAL HEATH DISTRICT <br /> FOI :OIFICE 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 3 <br /> (Complete In Triplicate) <br /> Application is hereby made, to the San Joaquin Local, Health District for a permit to const'r'uct <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 -7 e n7j CENSUS TRACT <br /> Owner's Name Phone <br /> Address S� 17 <br /> -✓ City 64 =i. <br /> 4 Contractor's Name License # phone <br /> TYPE- OF WORK (Check): NEW WELL / / DEEPEN J�/ RECONDITION /_ / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMA' REPLACEMENT : <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private... - Drilled Dia.. of Well Casing Y . <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 w ..,, _ _ .H.P. <br /> PUMP REPLACEMENT: /X/- � <br /> State Work Done " g � , <br /> PUMP TtEPAIR: <br /> � / / State Work Done . <br /> i <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 gutting the well in use. The above <br /> F information is true to the best. of my knowled=a , lief <br /> M <br /> SIGNED <br /> {f (DRAW PL PLAN ONEVERSE SI ) <br /> k. FOR KPARTMENT USE ONLY <br /> PHASE I -- -� <br /> APPLICATION ACCEPTED ..BY - TE ��" 7C7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> CALL-FORA-GROUT.,INSPECTION .PRIOR TD=GROUTING AND.FINAL INS ON <br /> .. E H 1426 __ 5/731M <br />