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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I'OI. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No.lv - J <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. <br /> JOB ADDRESS/LOCATION T ��. _ CENSUS TRACT <br /> Owner's Name Phone ' <br /> � <br /> Address City F` <br /> Contractor's Name <br /> License # Phone .36 <br /> --// <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTLATION REPAIR / PUMP REPLACEMENT /� <br /> AL <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 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal lam' <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> n <br /> - 1 <br /> PUMP Type <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done rtf/L wU o � ��'` rl VQ W� <br /> 'A <br /> PUMP `tEPAIR= .. / / State Work Done <br /> Approximate Depth <br /> DF-TRUCTION OF WELL: Well Diameter PP P <br /> Describe Material and Procedure <br /> I <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 <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above k <br /> information is true to the best of my knowledge and belief. ]� <br /> SIGNED (/` �41�{,G9'. � � TITLE <br /> (DffAW PLOT PLAN ON REVERSE SIDE} -/ / t <br /> FOR DF2.4RTMENT USE ONLY <br /> PHASE I �► <br /> APPLICATION ACCEPTED BY DATE <br /> : ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION P E II INAL INSPE TION <br /> INSPECTION BY DATE -- INSPECTION BY DAT^ -' <br /> CALL FOR A GROUT INSPECTION PRIOR TO dROUTING AND FINAL INSPECTION." <br /> /731M <br /> E a 1426 .....__ <br />