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1��-M–JOAQUIN -LOCAL,HEALTH DISTRI%,/ <br /> - OFJIICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. � 1 <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP FERMI ftermit No. -11--74-J <br /> THIS PERMIT EXPIRES I YEAR FROM DAT to 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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION M <br /> CENSUS TRACT <br /> Owner's Name VC G .R m-, Phone <br /> Address ���� fJ , f P City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN I / RECONDITION I I DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC ThNK 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 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 Groat <br /> Other Other Information <br /> PUTT INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> T w <br /> PUMP 'PAIR: / / State Work Done <br /> 6 r( 7 !oa <br /> OBSTRUCTION OF WELL: Well Diameter �. a f� A proximate Deptha2, 57t r <br /> Describe Material and Procedure - -��114 <br /> r e- <br /> 1 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 my knowledge and belief. <br /> SIGNED t. _ _ TITLE <br /> (DRAW PLOT PLAIN ON REVERSE SIDE) <br /> FOR DEPARTMENT-USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / <br /> ADDITIONAL COi%nAENTS <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />