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SAN JO,A;QUIN LOCAL HEALTH DISTRICT #. <br /> r T. OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> �+ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.��_ 3 2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application ishe eby 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 rdinancpe� No. 1862 anA th Rules and Reltulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO7N CENSUS TRACT <br /> Owner's Name p, Phone <br /> Address _ 1�11� "``_7f ,�_-r��,�•�-��--city r� <br /> Contraetor's Name Pheme <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION / /_ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TA4K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ X 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 0�T <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor /�l�2 -. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work D ne <br /> PUMP UPAIR: / / State Work Done <br /> DESTRUCTION 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 <br /> D LERS REPORT of the well and notify them before- putting the well in use. The above_ <br /> inform ti Zis rue to bestA Lykkn=owled and belief. <br /> SIGNED : TITLE <br /> D P OT PL ON R VERSE SIDdE;2: <br /> FO,/DEPARTMENT USE -ONLY <br /> PHASE ',\I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COM]hJENTS: <br /> PHASE II G 0 I PHASE III/FINAL INSPECT ON <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />