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C- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE Yj ti Pe7rmi 7S- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . :,jp-%� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health district for a permit to construct I <br /> and/or install the work herein described. ' This application is made in compliance with Satz Joaquin; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONj6� f r �� � -`19-�6a! NIUS TRACT <br /> Owner's Name D /2— ` Phone 44-1-76 :> 67 <br /> Address . Ca �'`� City '' <br /> Contractor's Name D License '"��73Phor►e ��y0�7r� <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /-7PUMP INSTALLATION / MP/ PUREPAIR IX—PUMP REPLACEMENT /� <br /> AL <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> IN'TENDE'D USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: State Work Done "J <br /> .DFATRUCTION 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 TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE j T7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II _ <br /> . .T ITSPECT ON PHASE III/F AL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE 2 <br /> r <br /> CALL FOR A GROUT SPECTION PRIOR TO GROUTING AND FINAL INSPECTION <br /> E H 1426 -- - 5/731M <br />