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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 /> Ide <br /> PPLICATION 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 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 Joaqu <br /> CountyOrdinanceNo. 1l�862 and the Rules and Regulations of the San Joaquin Local Health District <br /> .t.4 G I" • 2a:-P30 -m <br /> JOB ADDRESS/LOCATION r �/ � A/ r <br /> ' .- CENSUS TRACT <br /> Owner's Name �� ��y � f, � �[� <br /> m d 7J-. Phone y6a -Y41 4 <br /> ' Address _ /gyp/ /D`��tNro city- .y <br /> Contractor's Name License ll�,�ij�tI Phone ,e <br /> 9' <br /> ' TYPE OF WORK (Check): NEW WELL /7 DEEPEN /_ RECONDITION /`j .DESTRUCTION /-] <br /> ' , PUMP INSTALLATION /—/ PUMP REPAIR <br /> Other / / 2� PUMP REPLACEMENT /? <br /> O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' JENAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ------------ <br /> (F <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j <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 d <br /> ' Other Rotary Type of Grout.. <br /> 1[ Other Other Information <br /> �4 <br /> ' PUMP INSTALLATIONt •contractor <br /> Type of Pump / /yn H.P. <br /> ' PUMP REPLACEMENT: _/ State Work Done <br /> PUMP REPAIR: State Work Done <br /> ',DESTRUCTION OF WELL: Well Diameter <br /> a 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 d. bel f. <br /> SIGNED - ga- ^! TLE Ti Gam, <br /> (DRAW T ON RE SE SIDE <br /> FUR—DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY�' DATE <br /> ADDITIONAL COMMANTS: �' <br /> PHASE II GROUT INSPECTION P j INAL INSPECTION <br /> INSPECTION BY I�. DATE INSPECTION'BY , DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND .FINAL INSPECTION. <br /> E H 1426 F 7/72 1M <br />