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m _ <br /> FOR'`OkYG USE• ?. J/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> !' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> b. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> w .. . - <br /> THIS PERMIT ,EXPIRES lYEAR FROM DATE ISSUED Date Issued <br /> �Y <br /> fApplication is hereby made to the San (Complete In Triplicate)Joaquin Local Health District for a permit to construct <br /> and/or Install the work herein described. This application is made in compliance with <br /> County Ordinance No. in <br /> 1862 and the Rules and -Regulations of the San Joaquin Local Health SDistrian ct. <br /> JOB ADDRESS/LOCATION /� � � n ?p L-TDAJ VE { <br /> , > CENSUS TRACT <br /> Owner's Name Phone3 <br /> Address <br /> City a <br /> Contractor's Name )A Ir— License # / <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /? DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP, REPAIR / / PUMP REPLACEMENT 17 <br /> Other <br /> a <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> e SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDER USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. , of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing „ r.Q 41 <br /> r, t-- <br /> Domestic/public Driven Gauge of Casing . <br /> IV <br /> V: Irrigation Gravel Pack 'Depth of GroaE'-Seal <br /> Rotary`; ,Other _ _ � y ' Type of Grout �. <br /> Other tOther Information A <br /> PUMP. INSTALLATION: Contractor <br /> eType 'of Pump '•ire✓,, <br /> ii. r H.P. <br /> PUMP REPLACEMENT: / / ;State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> v <br /> alSTRUCTION OF WELL: `b Well Diameter <br /> - � +-'�� -Approximate"Depth <br /> 'Describe Material and Procedure. <br /> I hereby agree to comply with all ,laws and regulations of the San Joaquin Local 8ealthJDistrict <br /> and the State ,of California pertaining to or regulating well construction. Within FIFTEEN DAYS I <br /> after completion of my work on a hew 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. Th above <br /> information is true to the best of my knowledge and belief. ? i <br /> SIGNED <br /> TITLE r r <br /> (DRAW PLOT ' ON REVERSE SIDE <br /> PHASE I FO EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED �.G� �f`�5 P7 <br /> ABDITIONAL COMMENTS: DATE -2--� �_ ._ <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHA II/ INAL INSPECTION <br /> BATE INSPECTION BY DATE {� <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL, INSPECTION. <br /> E H 1426 <br /> 7/72 1M %,;,— i <br />