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SAN JOA UIN LOCAL HEALTH DISTRICT <br /> 1-'O—F.-OFFICE USE: `'� 1601 E. Hazelton Ave. , Stockton, Calif. Sch, tt, lM- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. q ZZc1,4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Hereby rade 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 Reg u o the San Joaquin Local. Health District, <br /> JOB ADDRESS/LOCATS--4 ��1 CENSUS TRACT <br /> Owner's Na �.� -� rf Phone <br /> L� <br /> Address City <br /> Contractor's Name lin License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION Zg Pi,'MP REPAIR / / PUMP REPLACEMENT 1-f <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTRJ T�iK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TY E OF WELL CONSTRUCTION SPECIFICAT S S!`` <br /> Industrial IKCable Tool. Dia, of Well Excavation � <br /> Domestic/private fDrilled Dia. of Well Casing lJ <br /> Domestic/public Driven Gauge of Casing /Q _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done b <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 D S REPORT of the well and notify them before putting the well in use. The above <br /> inform <br /> a on 's ue to the best of my knowledge and belief. <br /> SIGNED TITLE p <br /> _ (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> Pt€ASE I <br /> ,'APPLICATION ACCEPTED BY - - �` DATE <br /> ADDITIONAL CON*1ENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ted-1/ - 7 t� T INSPECTION BY DATE r' TEO '7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />