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- 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT lJ ? <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �. Telephone: (209) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y / 5�ro is <br /> THIS PERMIT EXPIRES I. YEAR FROM BATE ISSUED Date Issued Z_: T - <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 /> t <br /> ,TOB ADDRESS/LOCATION k/ / CENSUS TRACT S ; <br /> Owner's Name � • Phone ` <br /> Address 0 � r o., �r/• City <br /> it <br /> Contractor's Name I Alt,', ! IA gg,I License # _103 Phone �/O <br /> TYPE OF WORK (Cheek): NEW WELL / / DEEPEN '/_/ . RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION /J PL"MP REPAIR / /N 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S. <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP '.EPAIR: / 7 State Work Done <br />,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 weil 'construction. Within FIFTEEN DAYS <br /> atter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 14ELL 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 S } :. TITLE ,..: <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY e6 DATE / �v <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. QP <br /> E H 1426 - "_ �/731M <br />