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IL a ov <br /> y ✓ JOAQUIN LOCAL HEALTH DISTRIC* <br /> FF—dT.—OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �l�- <br /> 3;/ - 2r'/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued o?-/- 7� <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and <br /> �7Regulations /of �t�he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��e2177gt) �� -4/DY'/% CN X11 T71YC�fo ,(i� CENSUS TRACT <br /> Owner's Name Phone <br /> Address /r2& �� S ,/�irldtl /CLI�jr. CityOF <br /> Contractor's Name Yz' License # Phone , (� -3 <br /> TYPE OF WORK (Check) : NEW WELL. DEEPEN RECONDITION / / DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION ITT_PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p <br /> Industrial Cable Tool Dia. of Well Excavation V <br /> Domestic/private Drilled Dia. of Well Casing <br /> -Domestic/public Driven Gauge of Casing .3/// " Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _// Rotary Type of Grout - <br /> - / Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 2EPAIR: / / State Work Done <br /> DF'TRUCTION 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DPW VZOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEe) <br /> — <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTI S-e Al Xrj PHAS IJ FINAL INSP =TION <br /> INSPECTION BY DATE INSPECTION BY _ DATE �{'l� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. <br />