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-77 <br /> - <br /> /N1 <br /> SANJOAQUINLOCAI���,HEALT�i DISTRICT <br /> FOR FICE USE: 602 E. Haz ltbri}--Av'e-- Stockton, Calif, <br /> Tel0'ho� (209) 466-6781 <br /> APPLICATION FOR{WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPXRES 1 YEAR FROM DATE ISSUED Da eued <br /> (Complete Iri Triplicate) <br /> Application is hereby made: to the -San Joaquin Local Health District for a rmit 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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name lL•,iG Phone z <br /> ti <br /> City ` - � f <br /> Address B <br /> � <br /> .. License # Phone <br /> Contractor's Name 4A <br /> — <br /> TYPE OF WORK (Check) : NEW WELL% DEEPEN "/ / RECONDITION /_]; DESTRUCTION /7 <br /> PUMP INSTALLATION '/ I PUMP REPAIR / I PUMP REPLACEMENT I- 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 <br /> Industrial Cable Tool Dia. of Well Excavation /4 <br /> Domestic/private =Drilled Dia. of Well Casing i � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ' D - <br /> Other. Rotary Type of Grout _ - <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> f <br /> PHASE I <br /> PLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ' DATE 3 <br /> '-INSPECT ION BY arm.- SATE ��� _ INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4172 <br /> E H 1426 137 <br /> J F <br /> l <br />