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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO). 01'FICE USE".­7 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r—_ Telephone : (209) 466-6781 '` c <br /> !'APPLICATION 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 rade 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. 1662 and the Rules an Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� �vQ SOS /Y•FAL CENSUS TRACT <br /> Owner's Name y j�601l_ (2 (�f S C,O Phone � <br /> ✓ "l <br /> Address G C, Z� f��/2 City ,7 U e CFo i�­ <br /> ,Contractor's Name �3 L/ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMPINS ALLATION PUMP REPAIR / / PUHP-- PLACEMENT <br /> Other <br /> -DISTANCE TO NEAREST: SEPTIC TANK StWER'LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL Cry CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Topp Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Do estic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other "` Othe, Information <br /> PUKP INSTALLATION: Contractor <br /> Type of Pump f H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 'PUMP 'ZEPAIR: <br /> / / State Work Done-' /�( S �/� /. 1 P ,e3 f} S L — S(t(A <br /> DFgTRUCTION OF WELL: Well Diameter -— Approximate Depth <br /> Deseribe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local-Health District <br /> .wand the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after comple of my work on a new well.,+I will•,,�ur%tti`sh' the' San Joaquin Local Health District a <br /> WELL DRILL RS RE` ORT of the well and notify them before putting the well in use. The above <br /> informatio is t)ue to the best of my knowledge and belief. <br /> SIGNED 111111 (/1 /j, TITLE <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I _ Zt-1 <br /> APPLICATION ACCEPTED BY DATET7— <br /> ADDITIONAL COM1i!ENTS: <br /> a PHASE II . E PHAS ITS INSPECTION <br /> INSPECTION B <br /> ATE V INSPECTION BY DATE - ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN ON.% <br /> 7 u iA9f ff /'7gIu <br />