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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73_ _y9'.?z ; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <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 the San Joaquin Local Health District, i <br /> 4 <br /> JOB ADDRESS/LOCA'TION �� 5� �� �Ir��/'L -- - CENSUS TRACT �47 ' <br /> Owner's Marne Phone 6r`- �o15 <br /> Address 5 [�=�'"�L� /` !�Q City <br /> Contractor's NameLL f License # _ Phone <br /> TYPE OF WORK (Check) : -NEW WELL% DE EN /_~/T RECONDITION /_/— DESTRUCTION /? ~ <br /> PUMP INSTALLATIO PLW REPAIR f / PUMP REPLACEMENT /7 <br /> Other ,/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SE14AGE 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> I` Other Rotary Type of Grout <br /> Other Ot r Inforat'on000, 00 <br /> PUMP INSTALLATION: Contract— <br /> Type o Pump _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: f / State Work Done <br />�E ,DFGTRUCTION 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 try 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 /> inf tion i ru to the he t of my knowledge and belief. <br /> f <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIE) <br /> FOR DEPARTMENT USE ONLY <br /> I' <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE 3 - <br /> f' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II' /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE/0 .3 <br /> Ji CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> x 1�2h 5/731M - <br />