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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FApplication <br /> SE: lbC�i, Hazelton Ave. , Stockton, Ca L_ r ��Telephone: (209) 466-6781P�lTL�4R�L—CAPPLICATION FOR WELL CONSTRUCTION OR PUMP erm No. 2--5 7THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued(Complete In Triplicate) <br /> is hereby de to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application ismadein compliance with San Joaquin <br /> County Ordinance No. 1862 land the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1�-I�y fY�Ar�ooc CENSUS TRACT C,4k <br /> Owner's Name y r�V�p Phone SCK <br /> Address City <br /> Contractor's Name �i2#�p1 pj License 149441M Phone TaJaC610 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /-T DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION I�/� PUMP REPAIR/7—Pump REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKSQ 01 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 Grout �\ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> ,pESTRUCTION 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 r to the bes of my knowledge and belief. <br /> SIGNE e lh . t TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` n <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _a$ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. <br /> E H 1426 4/72 1M C9- <br />