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!/ <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT _ <br /> F'OL'OF'I IC4 USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7S-5L� <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION "7 8' / , ori J (N a[ CENSUS TRACT <br /> Owner's Name /Yl tm /iCG!//1 it Phone <br /> Address 2' AJ / r <br /> dllO.[ �✓ /e i� - -= - -- City <br /> .s <br />_ Contractor's Name - License #/,&,71,J Phone jf!r '.�GA <br /> TYPE OF WORK (Check) : NEW WELL f / DEEPEN RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION /—/ -PUMP REPAIR / f_PUMP REPLACEMENT /- <br /> Other •/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Driven Gauge of Casing <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 REPAIR: IXI 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 /> li 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 .i <br /> WELL DRILLERS REPORT of .the well and notify them b.e ofre putting the well in use. The above � <br /> information is true to the best of my know d e and elief. <br /> SIGNEk�p/ TITLE <br /> Ile- PRLOT PL ON R RSE SIDE) <br /> FOR DFVARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE Ll`� <br /> ADDITIONAL COMNMNI <br /> PHASE II GROUT INSPECTION PHA INSPECTION <br /> INSPECTION BY DATE INSPECTION BY BATE <br /> i <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING.AND FINAL INS <br />