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1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR ALL CONSTRUCTION OR PUMP PERMIT Permit No.` 7 <br /> THIS PERMIT'.EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <br /> - (Complete In Triplicate) <br /> Application ishereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the- work herein described. '-This, appl,i.cation is made in compliance with San Joaquin ; <br /> County Ordinance No. ,1862 and the Rules and Regulations of the San Joaquin Local Health Digrrict. <br /> JOB ADDRESS/LOCATION. I.S CENSUS TRACT <br /> Owner's Name Phone <br /> �J Sq City ' . <br /> Address <br /> License '+] Phon ! <br /> Contractors Name ' l � <br /> TYPE OF WORK (Check) : NEW ,WELLDEEPEN/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION � PUMP REPAIR J / 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 /> � Arivate Drilled_ , i_ _m.7 Dia.. o� Well Casing - <br /> Domestic/ Dri ,, <br /> p � ,y. r__�_ . <br /> Domestic/public r Driven Gauge of Casing <br /> Irrigation( Gravel Pack Depth of Grout Seal . <br /> Other Rotary Type of Grout <br /> Other: Other Information t <br /> i <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done - <br /> PI& REPAIR:. / / State Work Done -C <br /> 0 / A roxima-te <br /> -Depth <br /> P_*=CTION OF'WELL: Well Diameter `,{/C�/J -�Y p.p <br /> De c "be, <br /> Lal and-l'ro d re <br /> I hereby agree to. c nply with all laws and regulations of the &an Joa n Local He lth District <br /> 'E and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> i after completion of my work on .a new well, I will -furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT`6f '.the well and notify them before putting the well in use. The above <br /> information is true to the'best of my knowledge and- belief. <br /> SIGNED TITLE jL <br /> . (DRAW LOT PLAN ON REVERSE SIDE)_ <br /> i - <br /> FOR D PARTMENT USE ONLY <br /> PHASE I / DATE <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COI` MNTS: <br /> PiIASE II GROUT INSPECTION _ 1 PHE /FIN INSPECTI <br /> INSPECTION BY DATE 'l I "? IDTS C ION 4AS <br /> DATE•.CALL• OR•A GROUTAINSPECTION-PROUT NG.AND_FINAL .INN. <br /> _ F. H 1426 -� - - 5/731M- <br />