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SAN JOAQUIN LOCAL HEALTH DISTRICT '. <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �7 <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELC GONSTRUGTIONKOR PUMP PERMIT Permit No.> <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issuedt <br /> _ { (Complete In Triplicate) <br /> Application is hereby made to th6_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. <br /> JOB ADDRESS/i2ft== e-��A W,16h4el CENSUS TRACT _ <br /> Owner's Name 1�Q►� Phone 3✓��j'7�1 <br /> Address - City <br /> s� <br /> License #,� hone " <br /> Contractor's Name ��Pi� <br /> i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 t <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ��/-SEWER LINESrQr'} 7f PIT PRIVY r� <br /> SEWAGE DISPOSAL F ELD CESSPOOL/SEEPAGE PITAp`-OTHER <br /> PROPERTY LINF/40P'RIVATE DOMESTIC WELOYL"rPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFIC ATI NS {� <br /> Industrial Cable Tool -,Dia. of'-Well Excavation Z <br /> Domestic/private Drilled Dia."-of Well Casing S�' <br /> �— Domestic/public ``z. Driven Gauge of Casing ✓Z�lk __ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic-Protection Rotary Type of Grout <br /> Disposal Other Other Information F <br /> Geophysical Surface Seal Installed B ' <br /> OQ <br /> PUMP INSTALLATION: _Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT / / - State Work Done <br /> PUMP .REPAIR: / / Stmt WorkZone� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> I hereby agree to comply with -a11: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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION <br /> SIGNED <br /> 2MMT P ''ON REVERSE SIDE) <br /> l <br /> OR DZPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II NSP C ION P /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TP <br /> E H 1426 Rev. 11, oej 4 1r7f 1'.:..t7 Zw <br /> 2M <br /> Com✓ <br />