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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . FOF.:,OFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> UNED <br /> Telephone:p (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?3-_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9 >�3 <br /> k (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Ik and/or install the work herein described. ' This application is :Wade in compliance with Sax Joaquin <br /> County Orddinancvs, No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADD SS/LOCATION .A`L'L 6 E�i'�a I j ` CENSUS TRACT s <br /> Owner's NameA - PhoneKA <br /> Address !7 / City ' <br /> Contractor's Name l� fJ_ License 4 Phone [a �/ <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLAT 'MP REPAIR / / PUMP REPLACEMENT /� s <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC T)V4K 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 /> Domestic/private Drilled Dia. of Well Casing s <br /> Domestic/public Driven Gauge of Casing (� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP IN5TALLATION: Contractor <br /> Type of Pump _ H.P. <br /> E <br /> PUMP REPLACEMENT: / / State Work Done <br />,_PUMP. `tEPAIR:. T /../, _State,Wark.,Done <br /> .DFgTRUCTION OF WELL: 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. 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 DR RS REPORT of the well and notify them before "gutting the well in use. The above i <br /> inform tion tru the best of m knowledge and belief. <br /> SIGNED . :. �..,r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BYt <br /> DATE <br /> ADDITIONAL COMMENTS: - - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE/I -.? <br /> CALL FOR A GROUT_ INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 c�/711 Nr <br />