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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. Z&- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> s <br /> JOB ADDRESS/LOCATION r- CENSUS TRACT k <br /> Owner's Name - Y2 Phone <br /> Address City ; <br /> Contractor's Name F (y^..� License �� (t3 honeg- :11 <br /> f <br /> TYKE OF WORK (Check): NEW WELL '/ 'EEPEN/J -RECONDITION DESTRUCTION <br /> PUMP INSTALLATION 14UMP44� REPAIR / / PUMP REPLACEMENT /7 v r <br /> Other / / — r <br /> DISTANCE TO NEAREST: SEPTIC ITANK, f.S,EWER.#LINE IT PRIVY { <br /> SEWAGE DISPOSAL FIELD ESSPOOL/SEEPAGE PIOTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation d + E <br /> mestic/private i Drilled Dia. of Well Casing j <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation '4 Gravel -Pack Depth of GroutSd ..d�S•�� <br /> Other !rotary Type sof Grout; Xlj�� <br /> i Other r Other Information <br /> PUMP INSTALLATIONS Contractor <br /> Type of P !Kk� H.P. ,i <br /> r , <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP_.REPAIR: ,, / / jState Work. Done - -- — .. �,r► <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k 1 � <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 ;,,,l <br /> after completion of my work ori a new well, I will fisrnish 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 t` i <br /> info tion is true to b owledge and belief. } <br /> SIGNED TITLE <br /> +, <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHAS <br /> APPLICATION ACCEPTED BY DATE l �d <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION i <br /> INSPECTION BY DATE - - INSPECTION BY DATE <br /> t _ _ !f <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING "AND FINAL INSPECTION. <br /> E H 1426 0 ;� <br />