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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:01FIC� USE:.-,. 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z. =�`Ild <br /> Z-5-- <br /> THIS <br /> s=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/oz install the work herein described. , This application ismade 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 �, 1a"�' � c CENSUS TRACT , <br />'4 <br /> Owner's Name Phone <br /> city <br /> Address --- '-- --- <br /> Contractor's Name License'- EO N. (phone 4 - 4 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -f-/ RECONDITION / / DESTRUCTION 1-7 <br /> PUMP INSTALLATION / PUMP REPAIR / / -,.,PUMP REPLACEMENT <br /> z Other <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> E ; F STOWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL ,} CONSTRUCTION SPECIFICATIONS <br />$ Industrial ` Cable Tool Dia, of Well Excavation 04 6 <br /> s Domestic/private = Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation , Gravel Pack Depth of Grout Seal �Q <br /> Other Rotary Type of Grout ,. V <br /> Other Other Information <br /> M <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Dome <br /> PUMP 'tEPAIR: - / / State Work Done <br /> DFgTRUCTION 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 'consrruction. 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 he well and notify them before putting the 11 well in use. The above <br /> information is tr to the best of my knowledge and belief. <br /> SIGNED777�� TITLE . .�+t.+r <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> 1 FOt-DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE -, <br /> ADDITIONAL COMMENTS: <br /> P E II ,GR T INSPEC P S I/F AL INSPECTION <br /> INSPECTION BY DATE P C I DA <br /> a - CAI -FOR-•A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ION. 10j <br />