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A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l-,//_-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 made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Re ulatiQns of the Sanjoaquin Local Health District. <br /> C <br /> JOB ADDRESS/LO AT ",ION CENSUS TRACT <br /> FZ 3- <br /> /.4 <br /> Owner's Name Phone 7-7 <br /> Address X01 City <br /> 4 <br /> �w y 21,osqz. -5t4/-9X73 <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEM -7 RECONDITION DESTRUCTION /-7 <br /> PUMP INSTZLATION'/—/ PUMP REPAIR REPLACEMENT- /-7 <br /> Other <br /> A^ <br /> -- -- = <br /> DISTANCE TO NEAREST: SEPTIC T K7SEWER LINES-7-- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIYJATION <br /> Industrial Cable Tool Dia. of Well Excavation 44 <br /> Domestic/private Drilled Dia. of Well Casing z=1 <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 /> 1 4 <br /> PUMP INSTALLATION: Contractor <br /> !�Mr -- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUN? UPAIR: State Work Done <br /> .,DFqTRUCTION 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the will in use. The above <br /> info rahtticknj" tp the best of my knowledge and belief. <br /> SIGNE100 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOP, DEPAR%ME)9 USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED y <br /> I DATE <br /> BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E-I'Ll DATE /0 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 /731m <br />