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SAN :TOAQUIN LOCAL HEALTH DISTRICT <br /> FOT'.;OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued� d�7 3 <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 Sart Joaquiz <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health Distzict. <br /> .TOB ADDRESS/LOCATION S _ "' Si1S.�'TRACT 205' I&o-cT <br /> t _ <br /> Owner's Name C /V esad Phone <br /> E38- 27kff- <br /> Address <br /> Contractor's Name <br /> License <br /> �!: .. 7 d_ Phone <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN/_/ RECONDITION / DESTRUCTION /_7 <br /> r PUMP INSTALLATION () Pi1MP REPAIR / / PUMP REPLACEMENT J_ <br /> Other ;/ / <br /> s DISTANCE TO NEAREST: SEPTIC TAiINK 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 <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 ,� A�) <br /> I Type of Pump H.P. . . . <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP UPAIR: / / 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 /> SIGNED .— <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BY DATE `d <br /> ADDITIONAL COi�itENTS: — <br /> PHASE II GROUT INSPECTION PRASE III/FINAL IN5PECTIO <br /> INSPECTION, BY DATE INSPECTION BYDATE �. <br /> t <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. <br /> E H 1426 r <br />