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�.Y <br /> V ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> mr.�orriu us :. 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 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION v (4Vo /I� �_ CENSUS TRACT <br /> Owner's Name ®�t l�+��d/7 !'.S-- / c� -------.-. - Phone <br /> Address City 66 1 <br /> Contractor's Name License # l� —Phone " (meg_ 47o <br /> i <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/-/ DEEPEN "/ / RECONDITION /_{ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool tDia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Dornestic/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 Cam . an <br /> Type of Pump T a,� H.P. <br /> PUMP REPLACEMENT: /)C/ State Work Done _?awl <br /> PUMP REPAIR: / / State Work Done <br /> DF1ZTRUCTION 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 /> :iffier completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 14ELL 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 knowle e and-b- lief. <br /> SIGNED �. TLE <br /> o (I3 11 LOT IvLffON RE RSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - W DATE <br /> ADDITIONAL COMMENTS: - - <br /> PHASE II GROUT INSPECTION P11ASP, III/Y;AL I SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> • CALL FOR A-GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.. <br /> -T -Ttnr- K/7 -im <br />