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I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF-:OFFICE USE: '' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.. ,.3- <br /> 7-3.- 3S`1 p <br /> 1[ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued lu /6=Z3 <br /> (Complete In Triplicate) <br /> Application is hereby .,ade to the San Joaquin Local Health District for a permit to consta:uct <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. l.ealth District. <br /> ,TOB ADDRESS/LOCATION � > <br /> CENSUS TRACT S <br /> Owner's Namur , /�" ��V 11 bee -Phone <br /> Address City <br /> �" <br /> Contractor's Name License #,;)A 'Phone S69 <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR'/ / PUNP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool . Dia. of Well Excavation <br /> Domestic/private ]Drilled _ -- Dia.F of Well Casing <br /> Domestic/public Driven Gauge of'Casing <br /> ( Irrigation ' Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> F it Other Other Information ' <br /> PUMP INSTALLATION: Contractor C� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / State Work Done <br /> .DF.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> i <br /> I hereby agree to comply with all lags 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 a."Ly work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DR ERS REPORT 'af .the well and notify them before putting the well in use. The above <br /> inform tion 's tru o tpe best of any knowledge and belief. <br /> SIGNED <br /> .�� TITLE -- <br /> II (DRAW PLOT PLAN ON REVERSE SIDE) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE <br /> I <br /> APLI DATE ID ZC+2� <br /> � APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTIONPHASE III/FINAL INSPECTION <br /> INSPECTION BY eIM DATE f/ - -7s? INSPECTION BYDATE _7 <br /> 31 <br /> CALL FOR A GROUT INSPECTION PRION TO GROUTING AND FINAL INSPECTION. low <br /> E H 1426 II, - 5/731M <br />