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FOL_OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTR <br /> 1601 E. Hazelton Ave. ICT <br /> Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THISPERMIT EXPIRES 1. YEAR FROM DATE 'ISSUED <br /> (Complete In Triplicate) Z <br /> Date Issued 7� <br /> Application is he' <br /> made to the San Joaquin Local .Health District for a permit to con6truct <br /> and/or install the work herein desciribed. - This application is made in compliance with San Joa <br /> I County Ordinance Na. 1862 and the Rules and Regulations of the San Joaquin. Local 14ealth Dis Quin <br /> JOB ADDRESS/LOCATION �`et' <br /> -. cENsus Ti�ACT <br />� 'Owner's Name �.— . <br /> Phone �- 7a 7� <br /> Address _ �n <br /> City . . <br /> Contractor's Name <br /> License <br /> Phone <br />• TYPE OF WORK (Check) : NEW WELL / / DEEPEN _ <br /> / / RECONDITION /� DESTRUCTIONS / <br /> PUMP INSTALLATION PUMP REPAIR / UMp REPLACEMENT /�• -1 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC Ti1NK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE .DISPO5AL FIEID CESSPOOL/SEEPAGE PIT- OTHER <br /> INTENDED USE 1 <br /> TYPE C3F WELL _ CONSTRUCTION SPECIFICATIONS <br /> Industrial '�'-""""". "�"'�" o� <br /> Cable Tool p� Dia:- of Well Excavation \ "I <br /> Domestic/private Drilled <br /> Domestic/public i Dia• of Well Casi <br /> Driven ng <br /> Irrigation Gauge,of Casing, <br /> Other Grave] Pack Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other _ Other Information <br /> f <br /> PUMP INSTALLATION: Contractor <br /> 1� <br /> Type of Pump 5 v <br /> H.P. <br /> PUMP REPLACEMENT: <br /> State Work°Done <br /> PUMP UPAIR: d'J Work <br /> / State 'Da "'---% <br /> xie <br /> DFRTRUCTION OF WELL: Well Diameter t" <br /> Describe Material and Procedure ApproximateDepth <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 these before putting the well in use. The above <br /> information is rue to the best of my knowledge and belief. <br /> SIGNED <br /> TITZE _ <br /> (DRAW PZOT PLAN ON REVERSE SIDE} ------------ <br /> PHASE I TORDEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ,BY Z7,loe <br /> ADDITIONAL COMMENTS: JDATE <br /> PHASE II G INSPECTION <br /> INSPECTION BY PATE P S II /F AL IN <br /> INSPE ION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5 <br />