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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t-Or.-OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,�_SSS 4/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby rade 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 Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regula ons offtthh�e� nJ_oacuin Local Health District. <br /> Y71JOB ADDRESS/LOCATIONW&I J CENSUS TRACT <br /> AF W <br /> Owner's NamePhone <br /> 4 z L6 0 <br /> Address 9 t, City <br /> Contractor's Name ' ' /o ense c' 77��'�` hone'`%K_f <br /> TYPE OF WORK (Check) : NEW WELL _ DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /=T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TA 1K SEWER LI4ES _4,1 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES POOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF CONSTRUCTION SPECIFICATIONS <br /> Irulustrial able Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing <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 H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP 'ZEPAIR: / / State Work Done <br /> ,DFRTRUCTION 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 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 we,11 in use. The above <br /> information is/Tile to the be f my knowledge and belief. <br /> SIGNED . TITLE <br /> (D LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PEiASE I -y <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL. COMMENTS: �~ <br /> PHAS' II GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE j- 3C)_- 13 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />