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L <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFF17CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � I <br /> 1— <br /> i <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 Joaquii <br /> „County Ordinance No. 1862 and the Rules and R tions of the San Joaqu n iealth District. <br /> �! £- AD <br /> F <br /> -JOB ADDRESS/LOCATION � �- - ,I�" --' TRACT <br /> ` wn <br /> `Oer's Name CQ44 G41r1_ ( <br /> � DG4kl pt qui aI Phone / <br /> Address a. jt�a S�� City ��d'_( t <br /> b / , <br /> Contractor's Name �I�l t iC`� �- License Ql kr'Phone <br /> E <br /> V _ _ <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PLW REPAIR & PUMP REPLACEMENT j7 <br /> ` Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ` a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Dia, of Well Excavation <br /> r Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ' <br /> _ e Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 6PUMP INSTALLATION: Contractor <br /> Type of Pump u H.P. 30 <br /> tea?/na rrrx 6¢eo/Les.0 <br /> ,„PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / State Work Done / /p ! 4ee."I'l <br /> `,DFRTRUCTION 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 /> 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 /> informatiois true to the best of m kn wl ¢�ge and. elief. <br /> r <br /> SIGNED / / �. �M TLE .. . <br /> ( LOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I // <br /> �APPLICATION ACCEPTED BY DATE ��� �J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I/FINAL INSPECTION <br /> `, INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />