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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F°OF..OkFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7U a 9GJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby Wade 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. Neal.th District. <br /> JOB ADDRESS/LOCATION �J <br /> �,J' CENSUS TRACT <br /> Owner's Name __.. . . _f� J� I, AI.Slrb <br /> _ -- Phone <br /> Address City <br /> Contractor's Name � "1&! JP CC License # 71,642 Phone <br /> TYPE OF WORK (Check) : NEW WELL .J / DEEPEN /_/ RECONDITION /_/ DESTRUCTION f? <br /> PUMP INSTALLATION / J PIW REPAIR / / PUMP REPLACEMENT /7 <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 Q <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4 <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 X Rotary Type of Grout "4v <br /> Other Other Information 6t 7 <br /> PUMP INSTALLATION: Contractor ; <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP VPAIR: / / State Work Done <br /> ,DF9TRUCTION OF WELL: Well Diameter Approximate Depth y <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 <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 Qf .the well and notify them before putting the well in use. The above <br /> information " e the best of my knowledge and belief. <br /> 1 � <br /> SIGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)-- <br /> FOR <br /> IDE)FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY cf, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE ZY INSPECTION BY DATE 4- jr- <br /> _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />