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a <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF6F.�orncE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby rude 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 ADDRESSILOCATION CENSUS TRACT ' , <br /> Owner's Name /.�/�.�_o.,c.r� �ss, Phone ®gam/ I <br /> Address City r 1 <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / f PUMP REPAIR / / PUMP REPLACEMENT . <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERCo <br /> (� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q" <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 /> r <br /> PUMP REPLACEMENT: S tate Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DFsTRUC'TION 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 5 <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS j <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 knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I r <br /> APPLICATION ACCEPTED BY DATE a72 <br /> ADDITIONA , COMMENTS: <br /> PRASE 11 GROUT INSPECTION P SE I 'F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -= <br /> . CALL FOR-A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ' GO <br /> a <br />