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SAN JOAQUIN- LOCAL HEALTH DISTRICT <br /> FO£..Ol'IICE USE: ;-- . 601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone:. (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> r <br /> (Complete In Triplicate) <br /> Application is hereby spade to the San Joaquin Local Health District for a permit to construct <br />` and/or install the work herein described. , This application is mads in compliance with Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Re lat&ons of the Satz Joaquin Local -Realth. District. <br />` JOB ADDRESS/LOCATION rye? CENSUS TRACT <br /> C <br /> Owner's Name Phone <br /> Address r+ 4t City <br /> Contractor's Name �AJ tee. License ,yPhone $.-7`74 <br /> TYPE OF'WORK (Check): NEW WELL /% DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / /r PUTM? REPAIR /9/ PUMP REPLACEMENT /1_7Othe <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 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> - . . _._ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' I <br /> PUMP REPLACEMENT: / / State Work Done �1 <br /> 7 <br /> PUMP UPAIR: / / State Work Done a c: . <br /> .DFGTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 them before putting the well it use. The above <br /> information is true to the best of y ow :d�ge,.__�aift belief. <br /> ITLE <br /> D PMT LAN ON FRSE SIDE) <br /> PHASE T FOR DEPARTMENT USE ONT.Y <br /> APPLICATION .ACCEPTED .BY if - &fi& DATE Z 2, <br /> ADDITIONAL COM ENTS: i <br /> PHASE II GROUT INSPECTION P SE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B1 DATE F <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INS? CTION. <br /> E H 1426r i� <br />