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SAN JOAQUIN LOCAL HEALTH DISTRICT ` � h <br /> IOF. OFFICE USE: <br /> / 160 � <br /> 1 E. Hazelton Ave. , Stockton, Calif, `�t"t ` � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 5'/oLlJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , O_!1" 73 <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 /> -72So E , ovS-2&0--01? <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> 4 = <br /> Owner's Name Phone <br /> Address �j�. 6�� ' z, City <br /> Contractor's Name _ _ --- License # Phone .%S/ <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-T <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / FUMP REPLACEMENT /_7 _j . <br /> Other /_7 N <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial w Tool Dia, of Well. Excavation / <br /> tic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing p <br /> Irrigation Gravel Pack Depth of Grout Seal A.�.ttc-.. <br /> Other Rotary Type of Grout ,. <br /> Other Other Information <br /> PUTT INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP 'REPLACEMENT: f / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DFfiTRUCTION 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 is true to the best of my knowledge and belief. <br /> SIGNED TITLE � ti~v� = <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY �r�1 DATE �Q- S`?3 INSPECTION BY DATE & -,2_ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />'� E H 1426 5/731M <br />