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i SAN JOAQUIN 'LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1641 E. Hazelton Ave. , Stockton, Ca]-if. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR YELL CONSTRUCTION OR PUMP PERMIT Permit No.� S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � f <br /> (Complete In Triplicate) 6 <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/LOCATI J CENSUS TRACT <br /> Owner's Name Phone _361 <br /> Address city k <br /> Contractor's Name Licens/e9#3ZC_3 -Phon7. �4 3 <br /> TYPE OF WORK (Check): NEW WELL JX DEEPEN / f RECONDITION f"j DESTRUCTION /? <br /> PUMP INSTALLATION f / PUMP REPAIR / / PUMP REPLACEMENT f_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK Lb SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Tool Dia. of Well Excavation <br /> �mestic/private Drilled Dia. of Well Casing Q v <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Z�J <br /> Other Rotary Type of Grout 7_4 <br /> Other Other Information <br />' PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. It <br /> ' 1 <br /> PUMP REPLACEMENT: I / State Work Done <br /> PUMP REPAIR: f / State Work Done <br /> ,RESTRUCTION 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 /> rand 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 /> iWELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is tr a to th best of my kno ledge and belief. <br /> SIGNED TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED' BY � DATE T 7,11,(. <br /> ADDITIONAL COMMENTS: - <br /> . PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION .PRIOR...TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />