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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 'Oldl 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 26-$4',0r. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 � <br /> (Complete in Triplicate) <br /> Application is hereby made to- the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is trade in compliance with San Joaqui3 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San oaquin Local Health District. <br /> JOB ADDRESS/LOCATION i <br /> CENSUS TRACT <br /> Owner's Name ' Phone <br /> Address G <br /> -40 <br /> City <br /> Contractor's Name License �, Pho C �y <br /> TYPE OF WORK .(Check) : NEW WELL /% DEEP / RECONDITION /T DESTRUCTION /-7 <br /> 3 PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> ! Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES PIT .PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Z& af,A/ <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing \ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work one <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUC_TION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />{ I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> h after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED —,$/ TITLE �W <br /> (DRAW PLOT PLAN ON REVERSE SIA;4z <br />€ OR DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP Y �dWI ®� DATE _T <br /> ADDITIONAL COMMENTS: — <br /> PHASE II GROUT INSPECTION / PHAgr] Ii INAL INSPECTION <br /> INSPECTION BY DATE .INSPECTION BY DATE �-2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7I72 1M <br />