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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Ian.T!K. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-psr;y <br /> (Complete In Triplicate) <br /> Application is hereby wade to the San Joaquin Local Health District for a permit to consta:uct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquit <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION ��G � 4� �- �� et� / <br /> � c� CENSUS TRACT <br /> Owner's Nameh 11 - <br /> �.---•- Nth G, " . ..,_� t^- l r/i rs. ,a —..._.._._...._.__.,. Phone <br /> Address p !a 1 L?'f f Cit <br /> f y - t4/c _ <br /> Contractor's Name / � �,� {� License j a' " 'Phone A 74 <br /> TYPE OF WORT: (Check) : NEW WELL / / DEEPEN-/—/ RECONDITION 117 DESTRUCTION /_7 <br /> PUMP !NSTALLATION / / PUMP REPAIR /Y/ PUMP REPLACEMENT /-T <br /> Other / / <br /> DISTANCE TC tiL'AREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTI?"ND D USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X 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 /> PUNT INSTALLATION: Contractor <br /> Type of Pump -S - H.P. y <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: lY/ State Work Donen 7— 1� �s, .._ , <br /> DF9TRUCTION 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 /> ai& 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 knowledgeN, Lnd belief. <br /> SIGNED �,� �'/ �. �=��`C� � �'`. ��� �,. TITLE <br /> W P 0 LAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> AP?LICA'iION ACCEPTED BY /DATE � �Y <br /> ADDITIONAL C0 DENTS: _ <br /> Pl-ASEII GROUT INSPECTION P I NSPECTION <br /> INSPECTION BY <br /> PATE � INSPECTION BY, DATE <br /> CALL FOR A GROUT-INSPECTION PRIOR TO GROUTING AND FINAL INSk. ION. <br /> 7 - - �. <br />