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0,7. <br /> - SAN JOAQUIN LOCAL HEALTH biSTRICT ,per <br /> -071.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. "✓ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 „ pew <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5-- <br /> .(Complete <br /> '.(Complete In Triplicate) <br /> f Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herei ribed..' This a plication,, e i compliance with San Joaquin <br /> County Ordinance Na. a and g uin Local. Health 'District. <br /> JOB ADDRESS/LOCATIO / ' <br /> CENSUS TRACT <br /> Owner's Name - ' <br /> Phon$�r- <br /> VV, <br /> Address Citi} <br /> Contractor's Name �:_, 7 <br /> Y cense-,4;v <br /> TYPE OF WORK (Check): NEW WELL /_ DEEPEN.'/_/ RECONDITION / / DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK E ES PIT <br /> SEWAGE DISPO A FI ES�P00L/SEEPAGE PIT OTHER <br /> i 1 <br /> INTENDED USE TYPE OF CONSTRUCTION SPECIFIC IONS <br /> Industrial able Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well. Casing <br /> i Domestic/public Driven Gauge of Casing <br /> —L,., rigation Gravel Pack Depth of Grout Seal if 0 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> L PUMP INSTALLATION: Contractor ®cc,/new— <br /> 'Type of Pump <br /> F PUS P REPLACEMENT: / / State Work Done' <br /> PUMP 'zZPAIR: State Work Done ` <br /> ,DFsTRUCT.ION 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 o£ 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 wel and notify them before putting the l in use. The-above <br /> information true to the b of y knowledge and belief. � <br /> SIGNED TITLE <br /> (DRAW T PLAN ON REVERSE SIDE <br /> AV OR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED r DATE �i <br /> ADDITIONAL COMMENTS:ss . <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 6 -2 IN PECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. j <br /> E H 1426 /71�u <br />