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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr..DiFICE USL:,,o 1601 E. Hazelton-Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> T (Complete In Triplicate)• <br /> Ap` lication ,is hereby We to the San Joaquin Local Health District for a permit to ,construct <br /> a. /or install the wrork�erein described. ' This application is made in compliance with San Joaquin <br /> Co my Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District, a <br /> a <br /> JOB DRESS/LOCATIOiv ]SIQ0 6�,► ,G', n - CENSUS TRACT <br /> Owned.,s .Name lT r� ,�u v .o Q - Phone �G.� pill <br /> Addre s . h / a. City ,�1.2� <br /> Contractor's Name - . ����� � License # Phone ' � <br /> TYPE OF WORK (Check): NEW WELLIV DEEPEN '/ / RECONDITION f_1 DESTRUCTION /7 <br /> .PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT /7 <br /> Other /_7 — ---- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> iJ <br /> INTEND.ED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> j T Domestic/private ' Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> i Irrigation Gravel Pack Depth of Grout Seal _ r5_w T <br /> Other .a Rotary Type of Grout <br /> Other Other Information , '• . <br /> i <br />{ PUMP INSTALLATION; Contractor � ic•/- ,• _�/,,,,r.Lr r►r�. .1 <br /> Type of Pumpe-1 G� 114—e- tear H.P. —�.- <br /> PUMP REPLACEMENT: { / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DRqTRUCT-ION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby agree to comply with all laws and regulations of the San J165quin 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 />' <br /> information is true to the best of my knowledge and belief. <br /> � <br /> t <br /> pi SIGNED _ . -A -�_,Z I � - TITLE <br />.i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I / f <br /> APPLICATION ACCEPTED .B DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHAS VIII/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i � *�-CALL FOR A GROUT INSPECTION-PRIOR TO- GROUTING AND FINAL IN CTION. <br /> E.H 1426 _ _ 5/731M 1: <br />