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-SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone :p (209) 466-6781 370f <br /> APPLICATION FOR WELL CONSTRUCTION OR ?Ump PERMIT Permit No. 7,41- <br /> THIS <br /> _THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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 C c <br /> �� ' `r CENSUS TRACT <br /> Owner's Nam , <br /> Phone <br /> Address - j�2E City <br /> Contractor's Name Licens� <br /> - Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION F-1 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC Ti!-N''- SEWER LINE5 <br /> s PIT tBIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE�lF WETL ��- CONSTRUCTION SPECIFICATIONS � <br /> - Indus ial r} Tool Iiia. of Well Excavation <br /> mastic/private Drilled Dia, of Well Casing <br /> Z6�L <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation gravel Pack Depth of Grout Seal ` <br /> Other e <br /> Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - <br /> - - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR- / / State Work .done <br />,DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with allYlaws 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 he best of my knowledge and belief. <br /> SIGNED n <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -44111 <br /> ADDITIONAL COMMENTS; DATE <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY <br /> °" DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 C <br /> 7/72 1M -- <br />