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P-49� Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , -s-y rJ <br /> THIS PERMIT EXPIRES 1 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 stealth District. <br /> JOB ADDRESS/LOCATION _ � e2 r.� �+ , ,c� /. CENSUS TRACT 5+-!J <br /> i <br /> Owner's Name _��� _ �©_ _� VG � G✓_ Phone <br /> Address <br /> Contractor's Name License # Phon <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / f RECONDITION / / DESTRUCTION /-7 : - <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE FIT OTHER <br /> INTENDED USE TY E OF WELL CONSTRUCTION SPECIFICATI NS O <br /> Industrial f 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 Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> .DFRTRUCTION 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 a <br /> WELL DRILLER RT of the well and notify them before putting the well in use. The above <br /> information i tr to the best of m knowledge and belief. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SiBE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /0-3J -7/_ <br /> ADDITIONAL COMMENTS: �- <br /> PHASE II GROUT INSPECTION PHASE /FINAL INSPECTION <br /> INSPECTION BY DATE -2= -7 � INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />