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4 v *1\ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> C0—F. O1.7,1310E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 Rorkulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ZJ f— ji J CENSUS TRACT <br /> Owner's Name Phone �� " <br /> Address A-71 e CityCIO <br /> Contractor's Name License # S CS 4 Phone 7`1 2 <br /> TYPE OF WORK (Check) : NEW WELL /-41-- DEEPEN / / RECONDITION /_/ DESTRUCTION 1—T <br /> 'PUMP INSTALLATION _/�frFLW REPAIR / / PUMP REPLACEMENT /-7 <br /> Other " <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES _f IT PRIVY <br /> SEWAGE DISP AL iELD��CESSPOOL/SEEPAGE FIT _0 OTHER ---, <br /> h 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> 4--Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack's Depth of Grout Se <br /> Other Mary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump e-- H�Zdf - <br /> _ r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DFsTRUCTION 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 neva 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_knqxledge and belief. <br /> SIGNED <br /> TITLE <br /> PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHA I <br /> APPLICAT ACCEPTED BY <br /> DATE <br /> ADDITIONAL CO;IMMENTS: <br /> .PHASE IZ GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY CSS DATE !a i��s� INSPECTION BY - DATE !.2 / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 K/711m <br />