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SAN JOAQUIN LOCAL HEALTH DISTRIQT <br /> 1 F"O . OFFICE USE.--- 1601 E. Hazelton Ave. , Stockton, Calif. f F <br /> # <br /> Telephone:�._�. p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 5-24 <br /> yo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ze /�-,z3 <br /> (Complete In Triplicate) 2-SS- Z?U <br /> Application is hereby made o 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 Joaquf; <br /> County Ordinance No. 1862, and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address A 0 L&MCity <br /> Contraetarts name License # Phone ' S <br /> TYPE OF WORK (Check): NEW WELL ! / DEEPEN '/—/ RECONDITION /-7 DESTRUCTION /-7 ro <br /> PUMA INSTALLATION /y/ PUMP REPAIR /% PtTHtrP REPLACEMENT 1? <br /> Other <br /> V1 <br /> DISTANCE TO NEAREST: SEPTIC Tl,NK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool' Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public -- - Drivers Gauge of Casing ---- _ .---- <br /> Irrigation. Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> E Other Other Information <br /> PbW INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACu�TENT: / / State Work Done <br /> PUMP '4EPAIR: / J State Work Done <br /> .DFgTRUCTION 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 /> i 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 /> isformatioa is true to the best of my knowledge and belief. <br /> SIGNER TITLE „„ <br /> (DRAW PLM PLAN ON REVERSE- SIDE)-- <br /> FOR DEPARTMENT USE ONLY <br /> ._._2LICXfION ACCEPTED BY � c DATE <br /> ADDITIONAL C(3,2C-NTS: <br /> PHASE II GROUT INSP CTION PHASE ZI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE AA-23 <br /> CALL FOR A GROUT INSPECTION Pn10R TO GROUTING AND FINAL INS ON. <br /> f/7-4 <br />