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i <br /> _�1 JOAQUIN LOCAL HEALTH DISTRIn <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedf%} �7-]2 <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 Joaqui <br />` County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION T12.26J, CENSUS TRACT <br /> Owner's Name Phone %_3 m <br /> Address ."�"{ h� -- - - - - City �4-S C A I) <br /> Contractor's Namej License 41,,�Q Phone Ai s <br /> TYPE OF WORK (Check) : NEW WELL J / DEEPEN / / RECONDITION /_/ DESTRUCTION 1-7 <br /> PUMP INSTALLATION %Te�UM'P REPAIR / / PUMP REPLACEMENT /_T <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Cr <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> i <br /> 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 <br /> Other Other Information <br /> {9 <br /> 5 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , ��" ;h _. . -- - - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> j ,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 Distritt 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 my knowledge and belief. <br /> SIGNED J TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 01 �J <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> N - <br /> -ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E hIjaINAL INSPECTION <br /> 01. <br /> INSPECTION BY DATE INSPECTION BY ( DATE -2-0 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7172 1M �+o. <br />