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)117 0 J4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf.,OFFICA: USE: j, ,,16,01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�SG— <br /> THIS PERMIT EXPIRES 1 YEAR FROM nATE -ISSUED Date Issued <br /> (Complete In Triplicate) ^J <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 I ). / CENSUS TRACT <br /> Owner's Name <br /> .f Phone <br /> Address 7-10, 6 City '6 040.0."7,0,re <br /> Contractor's Name ��� ,�i, . License # 4V-2-1--L—Phone S4.,,2�4 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION / / DESTRUCTION /_7 Y <br /> PUMP INSTALLATION /ZT­P1JW REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> � d <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 w <br />' ?C Irrigation Gravel. Pack Depth of Grout Seal <br /> Other <br /> Rotary - Type of Grout <br /> _ Other Other Information ' <br /> PUMP INSTALLATION: 'Contractor <br /> 'Type of Pump H.P. 3O <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> /1r/ State Work Done <br /> .DFRTRUCTION OF WELL: 'Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> w <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 my Xnowledge an belief. t <br /> SIGNED <br /> / (D l T PLAN ON RWPRSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION FHA EIII/ INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ION. <br /> _E H .1426_ <br />