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SAN JOAQUIN LOCAL 11EALTU. DISTRICT , <br /> FOR OFFICE 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 I YEAR FROM DATE ISSUED Date Issued <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION LC/r,• CENSUS TRACT r <br /> Owners Named � � J Phone�jr/19 - _- <br /> AddressIl,, <br /> ®O EGE City A do <br /> - <br /> v • .� , .S License #/I,? Phone-3�334 �--� <br /> Contractor's Name f i41 - <br /> :S - �Pc j <br /> ,s <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN I_/ RECONDITION / / DESTRUCTION IJT <br /> PUMP INSTALLATION PUMP REPAIR'// PUMP REPLACEMENT � <br /> Others/'/ <br /> DISTANCE TO NEAREST: SEPTICfTANK SEWER LINES PIT PRIVY <br /> SEWAGE: DISPOSAL,, I;IELD ..``. CESSPOQLISEEPAGE PIT b OTHER . <br /> INTENDED USE TYPE OF WELL 1,1?CONSTRUCTION SPECIFICATIONS <br /> Industrial ,Cable Tool Dia.._nf Well .Excavation <br /> Domestic/private Drilled Dia. of Well Casing yV . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth af._Grout Seal a , <br /> Other Rotary Type of�_Grout ti A <br /> Other Information <br /> Other <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump J' H.P. <br /> -174 <br /> t / <br /> PUMP REPLACEMENT: / / State Work Done - , <br />'E PUNT .REPAIR• / / State <br /> t RESTRUCTION OF WELL: Well Diameter APPro xniate Depth <br /> Describe Material and Procedure y <br /> 1 I hereby agree to comply with all laws and regulations of the San Joaquin Local He <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 SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROJJT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE a '7� INSPECTION BY DATE " �'7.3 - <br /> I CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M . <br /> E H 1426 <br />