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ti <br /> l ... SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1.0f,.,O 'FILE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , /-7� <br /> (Complete In Triplicate) T <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 c.e CENSUS TRACT , <br /> Owner's Name a Phone 2- // ./L. <br /> Address jrrl 6 City :.? C <br /> Contractor's Name -. f� License # Phone G 2-•53­3�j <br /> TYPE OF WORD (Check) : NEW WELL /' JJ DEEPEN /_/ RECONDITION / / DESTRUCTION /? <br /> ALi <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT' /_ <br /> Other / / - — <br /> DISTANCE TO NEAREST: SEPTIC TANK 7,.5 SEWER LINES PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation j. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public . Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal fe' <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _ / / State Work Done i <br /> PUMP V-PAIR: _ /% State Work Done <br /> ,DFGTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ~` Describe Material'-and Procedure <br /> I hereby agree to comply with 411 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 /> informatto the best of my knowledge and bel ief.. �.. � <br /> SIGNED TITLE ---��� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I T �, <br /> APPLICATION ACCEPTED ':BY _� "_' .�"- �� DATE . �� -71� -�0, <br /> ADDITIONAL COMMENTS; <br /> PR&$E,:4- GROUINSPECTION PSE IIFANA14INSPECTIQ <br /> INSPECTION BY DATE _ /(2- /,g --73 ` INSPECTION-BY L&VATE Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ' <br /> TT 1 4-1G cf /7 2zu <br />