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,. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -f r.:o FICE .USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone. , (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No•. td <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> —I.. (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 Joaqui.l <br /> County Ordinance _No. .1862,and the .Mules and Regulations-of. the San Joaquin Local Bealth District. <br /> l `� P ' . <br /> JOB ADDRESS/LOCATION . [3 o.T (��.�, CENSUS TRACT '. <br /> Owner's Name L Phone r <br /> Address -_1 :p.. ... ... .. w mak- ._. City <br /> Contractor's Name License #242Q 2!2_GPhone 46 <br /> TYPE OF WORK (Check): -NEW WELL DEEPEN RECONDITION / / DESTRUCTION /-7 <br /> r . , PUMP: INS ATION / LW REPAIR "/ / PUMP REPLACEMENT /-7 <br /> i Other / / •.� j <br /> DISTANCE TO NEAREST: : SEPTIC TANK C?6— SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> G <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation +r <br /> Domestic/private 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 / / .i State Work Done <br /> PUMP UPAIR: /%. State Work Done <br /> DF.'TRUCTION OF WELL: Well Diameter Approximate�Depth <br /> Describe Material and Procedure <br /> I hereby agree to- comply uiith'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 he best .of my knowledge.-and belief. <br /> SIGNED r.""• <br /> TITLE ja,, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - �- DATE � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PH <br /> ASZ III FINAL INSPECTi " <br /> INSPECTION BY— DATE INSPECTION Bf DAT <br /> CALL FOR-A-GRGUT•-YNSPECTION,mPRIOR -TO GROUTING AND-FINAL-INSPECT 0351. 4 <br /> E H 1426 5/733-M <br />