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''6 SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> �FOf.:Oi'FICE USI:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> C 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 c;� <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 /> /z 3347 F. P%,v� / — <br /> JOB ADDRESS/LOCATION O}'t C4,c�cdr-� � r f 2i bra CENSUS TRACT <br /> Owner's Name & Phone <br /> Address a v f city C <br /> O &ZZ-U/4 a <br /> Contractor's Name .�--- _-- �/,, � _ License Phone 4,,44 f'fi 3�p <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION /! DESTRUCTION /? <br /> AL <br /> PUMP INSTLATION j / PUMP REPAIR /)U—PUMP REPLACEMENT /7 <br /> Other . <br /> DISTANCE TO NEAREST: SEPTIC TANK i 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 /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ] <br /> PUPA' INSTALLATION: Contractor 4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done j <br /> T <br /> iDFfiTRUCTION 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 /> j 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 /> t` SIGNED s <br /> C TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FO PART T USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEP DATE 'L[? v7 <br /> ADDITIONAL` COMMENTS: <br /> d PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION- BY DATE INSPECTION BY DATE 3 - Z� <br /> ------CAL -FOR A-GROUT INSPECTION--PRIOR-TO GROUTING AND,FINAL INSPECTION.- - _. r_d <br /> L, v ILgA 31m <br />