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SAN JOAQUIN LOCAL HEALTH DISTRICT. _ A,, <br /> FF_0F." <br /> :OFFICE USE: 1601 E. .Hazelton Ave. , Stockton; Calif <br /> f 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 S-/Y-76 <br /> (Complete In Triplicate.) <br /> Application is hereby riade tolthe San .7oaquin Local Health District for a permit to construct 4. <br /> and/or install the work herein described. , This application is made in compliance with San Jaaquiit'i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. � <br /> r� <br /> JOB ADDRESS/LOCATION- ���!' f � -��®�^-�- �� CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City . I <br /> �� � License # Phone <br /> Contractor's Name /moi yi__ _ <br /> TYPE OF WORK (Check) : NE14 WELL / / DEEPEN / / RECONDITION DESTRUCTION J 7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / P RE LACEMENT <br /> ©ther /� <br /> DISTANCE TO NEAREST: SEPTICITANK/6fp SEWER LINES PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> -Other I Rotary. Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATIONt, Contractor <br /> J�Q' e r fi <br /> ' - <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: I / iState Work Done Gil r <br /> PUMP 'tEPAIR: / / State Work Done'i,, <br /> _.. <br /> ,DFgTRUCTION 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 Distric <br /> and ,the State of California pertaining to or regulating-well construction. Within.FIFTEEN DAYS <br /> completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <br /> `WELL DRILLERS REPORT of the ;cell and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNEDk TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I4 <br /> APPLICATION ACCEPTED BY �: . DATE. . . fT 7 <br /> ADDITIONAL COMMENTS: <br /> PRASE II ROUTiINSPECTIOZ PHASE III/FINAL INSPECTIO <br /> INSPECTION BY +DATE INSPECTION BY G` r DATE <br /> CALL FOR-A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />;. ;� 5/731x2 <br />