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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF.:OI�FICA USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 t <br /> T_. APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. '7'3_� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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/LOCA.TION 1. -P f CENSUS TRACT <br /> Phone O / <br /> Owner's Name La. _ <br /> f Address ���y x �' 7`p� i r �P PIr , City — d�i�r -._ <br /> 6 � /- <br /> contracto�r s Name � � <br /> t Lic ,nse �� �p Q Phone 46 �� <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN /_/ RECONDITION / / DESTRUCTION /?1. <br /> PUMP INSTLATION b(/ PUMP REPAIR `/ / PUMP REPLACEMENT - <br /> ALf _. <br /> Other <br /> DISTANCE TO NEAREST:r SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES—SPOOL/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 <br /> - - Domestic/public Driven Gauge of Casing z <br /> Irrigation I Gravel Pack Depth of Grout Seal r <br /> I Other Rotary Type of Grout <br /> - Other Other Information - <br /> PUMP INSTALLATION: Contractor <br /> Type` of Pumpv H,P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP nPAIR: / / State Work Done <br /> PFSTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure'_,_ , L <br /> t 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 /> Y•, infr tion is true t he best of my knowledge and belief. <br /> SIGNS TITLE <br /> (DitAW PLOT PLAN ON REVERSE SIDE) <br /> ` <br /> FOR D-PART_MENT USE ONLY ..- .y <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE �G'- � <br /> ADDITIONAL COMMENTS: = <br /> PHASE II GROUT INSPECTIONP SE /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' 6f13 <br /> CALL-FOR A GROUT INSPECTION PRIOR>TO GROUTING AND FINAL INSPION. <br /> 5./7 3 IN <br />