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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 /b QGrJ¢ <br /> THIS PERMIT EXPIRES 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. 1862 ,and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION els' �` ^� CENSUS TRACT <br /> Owner's Name _ - r/!�/��� fie/ L1 .. �TCc.r ._ Phone <br /> �T 4 <br /> Address City 5 � <br /> Contractor's Name �/��� � License #,Z? Phone -�(-o6.p4 <br /> E <br /> TYPE OF WORK (Check): NEW WELL � DEEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> AL , t <br /> PUMP INSTLATION � PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT /2,Vl OTHER <br /> U <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation Iy _ <br /> ^_ a Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �s�p <br /> Other _ Rotary Type of GroutC <br /> Other Other Information . , - <br /> PUMP INSTALLATION: Contractor /7 <br /> Type of Pump H.P. f <br />' PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done - <br /> ,DESTRUCTION OF WELL: Well Diameter (�' '� _ Approximate Depth /�2Q <br /> Describe Material and Procedure <br /> I hereby agree to comply w th 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 REPO of the well and notify them before putting the well in use. The above <br /> information is ue to the b of my owledge and belief. <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 00DATE <br /> ADDITIONAL COMMENTS: <br />` P E II &G�EUT INSPECTI N PHA F INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FORA GRO INSPECTION PRIOR. TO GROUTING AND FINAL INSPECT /. <br /> E H 1426 7772 1M <br />