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i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0F. <br /> 021-'ICE USL. 1601 E. Hazelton Ave., Stockton, Califs. <br /> Telephone: (209) 466--6781 <br /> 1APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9c/-5"j-2/u) <br /> -1 r) <br /> 1 - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is her y made to the San Joaquin Local Health District for a permit to Construct <br /> and/or install the worts herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No, 1862xe er,-a f the San Joaquin Local lleal.th District. <br /> / G' <br /> f JOB ADDRESS/LOCATION C 5US TRACT <br /> Owners Mame <br /> a A <br /> Address Ci <br /> Contractor's Name License #=2 Phon <br /> E <br /> E <br /> TYPE OF WORK (Check); NEW WELL DEEPEN /% RECONDITION /7 DESTRUCTION /-7 <br /> TAL <br /> PUMP INSLATION REPAIR / / PUMP REPLACEMENT t-7 <br /> Other <br /> DISTANCE: TO NEAREST: SEPTIC Tl, qK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTE:NDEI? USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial able Tool Dia. of Well Excavation <br /> mestic/private. Drilled Dia. of Well Casing 1001^ orQ <br />'f Domestic/public Driven Gauge of Casing / <br /> 'Al 04M-1 <br /> ,,Pr'Fl-gation 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 /> 1, <br /> DFOTRUCTION 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 nd notify them before putting the we in use. The above <br /> informatioa z true to he be m knowledge and belief. <br /> SIGNED TITLE <br /> DRAW T PLAN ON REVERSE SI <br /> OR DEPARTMENT USE ONLY <br /> PiiASE I „ <br /> APPLICATION ACCEPTED BY _ _ DA'T'E <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION � PHASE IIS FINAL INSPECTION <br /> INSPECTION BY cs!!� — DATE INSPECTION By DATE l! . <br /> CALL FOR A GROUT INSPECTION PRIOR T GROUTING AND FINAL INSPECTION. <br /> H 1426 <br />, 5/ 31rs a <br /> i <br />