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t - <br /> re ; SAN JOAQUIN LOCAL HEALTH DISTRICT <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. 1--2 <br /> . <br /> ;12-/ <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> f (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 b, the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATT SIJ CENSUS TRACT ' S <br /> Owner's Name t4— 4171 or <br /> r Phone ' <br /> }` City <br /> Address <br /> Licen-se ` C <br /> Contractor's Name L [ <br /> e <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION /�---PUMP REPAIR / / PUNK,REPLACEMENT _ I�T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINE° O PIT PRIVY J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI NS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C -- <br /> Irrigation +' Gravel Pack Depth of Grout Seal .-VT, <br /> Other // Rotary Type of Grout �- <br /> Other Other Information ' . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump L. H.P. <br /> PUMP REPLACEMENT: / / State Work Done `r —IS 7 <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 /> informat rue to the s f my knowledge and belief. <br /> SIGNED TI <br /> RE SE SID ) <br /> FOR DEPARTMENT U Y <br /> PHASE I E` �2 T <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL CONI�ENTS: <br /> PHASE TT GROUT INSPECTION P TIT/ INSPECT f <br /> INSPECTION BY DATE INSP ION ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4172 1M <br /> E H 1426 <br />