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SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> FOR OFFZbt 1601 E. Hazelton Ave. , Stockton, C:AIJ.f. <br /> Telephone: (204) 466-6781 ` ;_ R <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued� S <br /> i (Complete In Triplicate) <br /> Application is hereby made tolthe 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 le 1.1;and Regulations of the San Joaqu Local Health District. <br /> JOB ADDRESS/LOCATION ENSUS TRACT <br /> Owner's Name p Phone <br /> Address ,3 City - 6?,6 <br /> Contractor's Name License # efL� PjsrMone70 <br /> y� <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_/ `RECONDITION /`7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /)T <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 5 <br /> Industrial Cable Tool Dia. of Well Excavation 6 <br /> _)C 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> a <br /> PUMP REPLACEMENT: W l'State Work Done _ <br /> 7 0A0 <br /> PUMP REPAIR, <br /> / / State.Work Done <br /> ESTRUCTION 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, in`use. The above <br /> information is true to the best of owled belief. <br /> SIGNE TLE <br /> { PLO LAN ON RF-_ RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I I FI INSPECTI � F <br />[NSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT.I N, <br /> E H 1426 7/72 1M <br />