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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Vol' <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued v2,2 /D <br /> 0 <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 S-(a.5 S' � l.�c.�a�a�,%��►,� ,� 1_�' - - - - - <br /> - CENSUS TRACT <br /> Owner's Naive Phone <br /> n - ; <br /> Address -�C City & M� <br /> A <br /> Contractor's ylVame z �,,,, ce fel[ �rai �� License �a f 6 Phone <br /> _ - - <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN -/7 RECONDITION /_/ DESTRUCTION /77 <br /> PUMP INSTALLATION /L�REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST:. SEPTIC TANK , p SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> s Industrial � able Tool Dia. of Well Excavation _ /!z � i <br /> Domestic/private Drilled Dia. of Well Casing -- <br /> ` Domestic/public Driven Gauge of Casing .3 I <br /> : igation f Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> ' Other Other Information ' <br /> UMC'.INSTALLATION: Contractor <br /> r Type of Pump H.P. ..2(D <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP�'tEPAIR: / I State -Work Done ., <br /> .DFCTRUCTION-OF 'WELL: `Weil"Diameter --`- �-` -.Approximate-Depth - <br /> Describe Material and\Proce.duret,' <br /> S <br /> I hereby agree to comply with all lavis `;td 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 abov <br />'I information is true to the best of my knowledge and belief. <br /> i <br /> SIGNED nax 40, TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> s PHASE I <br /> APPLICATION ACCEPTED BY � �` � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DA,�E <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO <br /> 917 q l we <br />