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v SAN JOAQUIN LOCAL HEALTH DISTRICT ? r... \. <br /> FOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. '�6 x'97 <br /> Telephone : (209) 466-6781 <br /> �'�3 � 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _3�;L_G 4� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) T <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 <br /> the San Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATION (�ILfi7TC '- CENSUS TRACT j <br /> Owner's Name <br /> Phone <br /> Address Q City -- <br /> Contractor's Name - License # Phone i <br /> TYPE OF WORK (Check) : NEW WELT, � DEEPEN /_% RECONDITION /7 DESTRUCTION /_7 �. <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 — — � <br /> DISTANCE TO NEAREST: SEPTIC TANK K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD X CESSPOOL/SEEPAGE PIT)( OTHER <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS '. <br /> Industrial Cable Tool Dia. of Well Excavation Y J <br /> X _ Domestic/private X Drilled Dia. of Well Casing x <br /> Domestic/public - Driven Gauge of Casing x <br /> � X _ Irrigation Gravel Pack Depth of Grout Seal ,-C <br /> Other Rotary Type of Grout x <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> kESTRUCTION 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 ue to the best knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE f _ �' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �.c.� <br /> E H 1426 7/72 1M <br />