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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70F.-OFFICE USE: (made <br /> 01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> --- _ TION FOR,,ALL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is herethe San Joaquin Local Health District for a permit to construct <br /> and/or install the described, , This application is made in compliance with San JoaquinCounty Ordinance Nothe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address 2 1 mJ . <br /> - r City ' <br /> Contractor's Name 0414 r-W- License 1 <br /> �j�13'�� Phone," <br /> TYPE OF WORK (Check) ; NEW WELL / / DEEPEN'/-/ RECONDITION /_/ DESTRUCTION 17 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / 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 /> Domestic/private X Drilled Dia. of Well Casing <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 INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> ,DFNTRUCTION 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 true to the best of my knowledge and belief. <br /> SIGNER ! <br /> TITLE � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I - <br /> FOR DEPARTMENT USE ONLY <br /> ” � <br /> APPLICATION ACCEPTED BY C� DATE - 4-1 4% <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION ~ P EUI/FINAL INSPE IO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 167t- <br /> -CALL i�S <br /> •CALL FOR A GRO YINSPECT�N�-PRIOR TO GROUTING AND FINAL. INSPON. <br /> E H_1426 K/71im <br />