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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. VOP <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 Health District. <br /> JOB ADDRESS/LOCATION * CENSUS TRACT <br /> Owner's Name � ,2�o-01 <br /> i. Phone7 <br /> Address � ,� ��... City ��. r✓ <br /> Contractor's Name � ,w fad. '', ,� _�i_ -_ -_-_ - License Phone 5� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR 9-/ PUMP REPLACEMENT /7 <br /> Other /% � �. <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 �W <br /> Domestic/private Drilled Dia, of Well Casing �r <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 /> f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r _ <br /> i PUMP REPLACEMENT° / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> ,RESTRUCTION 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 DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of #myg knowledge and belief. <br /> SIGNED ��C�',l „I�►��� :- L_�G .'(1"_�_,>.: - U q� � ��--- TITLE "AIA,it?"J­ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> + FOR DEPARTMENT USE ONLY <br /> - -- <br /> PHASE E I <br /> DATE <br /> ! ADDITIONAL <br /> APPLICATION ACCEPTED BY COMMENTS: - X <br /> PHASE II=ROUT PHOE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , DATE <br /> t 1 <br /> ;Jahr, < <br /> w CALL FOR A GROW INSPECTION PRIOR TO GROUTING AND_ FINAL INSPECTION. <br /> taut <br /> E H 1426 in <br /> 7/72 3.M <br />