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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fi r. 01'FICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> _ Telephone: (209) 466-6781 ) <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-7�- 3y,G1/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued T-8,7 <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 k/ 1 6 !i , a" +JE CENSUS TRACT <br /> Owner's Name �72 `' -LL�+ -c� cr-L Phone <br /> Address --/0 city �Cs-trk- <br /> Contractor's Name ..��%' '' License # 744,2� Phone Z-o�� % 7 <br /> TYPE OF WORK (Check): NEW WELL j / DEEPEN / / RECONDITION W DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/—/ PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANTO _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/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 Ell- <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; / / State Work Done <br /> PUMP UPAIR: j / 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 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 /> information is true to the best of my knowledge and belief. <br /> f e <br /> SIGNED ;� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> AI <br /> APPLICATION <br /> CATION ACCEPTED BY � DATE <br /> ADDITIONAL COMMENTS: <br /> PEASE II ROUT INSPECTION PHASE I /FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE j <br /> CALL FOR A GROUT I SPECTION PRIOR TO GROUTING AND FINAL INSPiqION. , <br /> E H 1426 731M <br />