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f� <br /> i ! S JOAQUIN LOCAL HEALTH DISTRICT <br /> �'O..OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I E� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I V (Complete In Triplicate) <br /> ;plication is hereby Wade to the San Joaquin Local Health District for a permit to construct <br /> „d/o'r install the work .herein described. ' This application is th San Joaquin <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the S#. Jo u l alth District. <br /> OB ADDRESS/LOCATIONCENSUS T CT <br /> wner's Name �� �,� �./�� 6P ill Phone C� $F <br /> M ddr6ss f'1'}Q- I�}$ 19-0jerr City <br /> E� _ <br /> :ontractor's Name _Ig <br /> License # :•211 75 Phone S3 9,Z-S_ <br /> VS <br /> 'YPEi}OF WORK (Check) : NEW WELL DEEP _/ RECONDITION / / DESTRUCTION <br /> i. PUMP INSTALLATION X PUMP REPAIR / / PUMP REPLACEMENT <br /> fi Other <br /> )ISTPuNCE TO NEAREST: SEPTIC TANK4 G1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ <br /> li <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation G <br /> i. Domestic/private;, Drilled Dia. of Well Casing C). 'I <br /> 1 Domestic/public - Driven Gauge of Casing <br /> <q cyf­ <br /> _eK. Irrigation Gravel Pack Depth of Grout Seal <br /> 11 Other Rotary Type of Grout <br /> i Other Other Information <br /> .i <br /> w <br /> 'L�iP�I INSTALLATION: .; Contractor <br /> II "Type of Pump _ H.P. 3 <5 <br /> PUIMFP REPLACE1,,1ENT: i / / State Work Done <br /> _U I State Work Done <br /> i MP' TtEPAIR: ,_ <br /> j� <br /> DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hdreby agree to comply with all laws and regulations of- the San Joaquin Local Health District <br /> i andthe State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> I 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 a otify them before putting the well in use. The above <br /> informati n 's t ue to the best o my owledge and belief. <br /> 9 <br /> SIGNED �� TITLE <br /> jj. (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PitiASE I 7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COZ-ZIENTS: <br /> 11 PHASE II GROUT INSPECTION PH S /FIN INSPECTION <br /> INSPECTION BY 41 14= DATE INSPECTION B DATE leZ--74:Z <br /> -CALL FOR A GROUT INSPECTION PRIOR_TO GROUTING AND FINAL INSPECTION. <br /> �/7 31M <br />