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7- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. o ve () <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�����J <br /> a <br /> THIS PERMIT EX FIRES 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/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 anf the Rules and Regulations of the San Joaquin Local Health District. <br /> 977y__a F 5FD 'rA/ Sc1.4h,. <br /> JOB ADDRESS/LOCATION' tl/ ENSUS TRACT ' <br /> Owner's Name 11` /` /�/ �L Q` I Phone X <br /> Address d S141 City -� <br /> e - <br /> Contractor's Name License( Phone)LA 213V <br /> TYPE OF WORK (Check) : NEW WELL /X DEEPEN /_/ RECONDITION / / DESTRUCTION /? <br /> LUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /—T 4 <br /> Other <br /> ,{DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES+ PIT PRIVY' <br /> SEWAGE DISPOSAL FIELD- CESSPOOL/SEEPAGE PITA- OTHER <br /> kINTENDED USE 'TYPE OF WELL ONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation x <br /> Domestic/private Drilled Dia. of Well Casing K31 <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 /> a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P- <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP VPAIR: / /-_ State Work Done <br /> DFRTRUCTION OF WELL: Well D ameter Approximate Depth _ 9 <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 i <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ��g <br /> TITLE <br /> f+ (DRAW PLOT PLAN ON REVERSE SID2) <br /> FO ARTMENT USE ONLY <br /> 5: PHASE I <br /> APPLICATION ACCEPTED TE <br /> ADDITIONAL COMMSNTS /f- <br /> PHASE II GROUT INSPECTION P S II AL INSPECTION <br /> INSPECTION BY DATE INSPE iON DATE <br /> f 4 <br /> - CALL FOR A GROUT INSPECTION PRIOR TO ,r 0, TING AND FINAL INSPECTI . . RD/`�'�� S <br />