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` SAN JOAQUIN'LOCAL HEALTH DISTRICT ' <br /> .'OFFICE f' 'B <br /> 0�' ICE USE: Y 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> . . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. SZ <br /> THIS PERMIT EX'IRES 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 /> r- r <br /> JOB ADDRESS/LOCATION ,lI�� � ` GENSUS TRACT <br /> Phone <br /> Owner's Name C.l �' <br /> City 's T-0 <br /> Address , <br /> LicensePhone <br /> Contractor's Name <br />- TYPE OF WORK (Check): NEW WELL DEEPEN/ / RECONDITION DESTRUCTION DESTRUCTION /_7 t <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7. <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK , 5EWER LINES , PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER q <br /> TION SPECIFICATIONS <br /> CONSTRUCTION b <br /> INTENDED USE TYPE OF WELL . <br /> Cable Tool Dia. of Well Excavation <br /> Industrial 7- <br /> Domestic/private Drilled <br /> Dia. of Well Casing ' <br /> Domestic/public <br /> Driven Gauge of Casing /.2. C <br /> _ <br /> Irrigation <br /> Pack Depth of Grout Seal <br /> Other Rotary 'hype of Grout � <br /> I Other Other Information <br /> PUMP INSTALLATION: ContractorH.i'. <br /> Type of Pump <br /> PUMP REPLACEMENT: / State Work Done <br /> UMP nPAIR: / / State Work Done <br />? Approximate Depth <br /> pF--TRUCTION OF WELL: Well Diameter <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 n a new well, I will furnish the San Joaquin Local Health District a <br /> [ WELL DRILLERS REI OR f the well and notify them before putting the well in use. The above <br /> informatia to my knowl ge nd belief. <br /> ! TITL - <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE s ). <br /> a <br /> FOR :DEPARTMENT =' ONLY • ' <br /> PRASE I �. DATE, 7 '7 <br /> `F APPLICATION ACCEPTED .BY <br /> 11 ADDITIONAL COMMENTS; <br /> PHASE I GROUT INSPECTION PHASE III/FINAL N5PECTIO <br /> DATE INSPECTION BY DATE 0 <br /> INSPECTION BY r <br /> -CALL FOR-A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 3 <br />