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SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOE-OFFICk USE: 1501 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 456•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 'Permit NJ.�,r/ $� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) � I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constIuct <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 HerlAh Districts <br /> JOB ADDRESS/LOCATION 4f_ CENSUS TRACT jj <br /> 1 <br /> Owner's Name Phone <br /> Address / 7 Ct� y Cityf <br /> Contractor's Nasse � &VA License <br /> . I! <br /> TYPE OF WORK (Check) : NEW WELL /P�"'DEEPEN .I_/ RECONDITION /_/ DESTRUCTION J <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other l ! <br /> DISTANCE TO NEAREST: SEPTIC TA1NK SEWER LIIES PIT PRIVY <br /> d <br /> SEWAGE DISPO AL FIELD L2 CESSPOOL/SEEPAGE PIT OTHER -: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable .Tool . Dia. of Well Excavation j` ` <br /> --T;;3"-Domes tic/private Drilled Dia. of Well Casing 6 NI E <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal F <br /> Other Rotary Type of Grout <br /> ---.- Other Other Informafion <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 'I <br /> PUMP REPLACEMENT: / I State Work Done <br /> PUMP UPAIR: / f State Work Done � <br /> E l DF(zTRUCTION OF WELL. Well Diameter _ Approximate Depth <br /> F Describe Material and Procedure <br /> A <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 FIiFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> q <br /> WELL DRILLERS REP 'I <br /> ORT 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 /> ; <br /> SIGNED TITLE _ /t.c4, . ----- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) al <br />' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 140 <br /> DATE 01A A <br /> ADDITIONAL COMMENTS: 6 �I t <br /> PHASE II GROUT INSPEC'%IOI <br /> PHW SII 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 -- 5/73im <br />