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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FO£.:OFFICE USE:- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �$ <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) i <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 Joaqui.n'l <br /> County Ordinance No. 1862 anis the Rules and Regulations. of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION T 111�lJ$® � 111.�1%4,41 A74�, . CENSUS TRACT <br /> Owner's Name Phone " D 31- <br /> Address <br /> 1-Address 3 City5T <br /> Contractor's Name �� License # Q(} Phoneg� { <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION /_/ DESTRUCTION /� <br /> PUMP INSTALLATIONPUMP REPAIR/ / PUREPAIR / / PUMP REPLACEMENT (7 <br /> Other / Q d Urf <br /> DISTANCE TO NEAREST: SEPTIC TANK /J:j SEWER LINES PIT PRIVY <br /> SE14AGE�DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /I <br /> Domestic/private A Drilled Dia. of Well Casing f� <br /> Domestic/Public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal V i7) f __ <br /> Other Rotary- Type, of Grout <br /> Other Other Information <br /> I, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> i <br /> , FRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 complet4 on 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 /> informati^ is true to the best of my knowledge and belief. <br /> i f <br /> j SIGNED TITLE _ ���/ e <br /> r 1 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED -BY DATE l <br /> ADDITIONAL COMrMNTS; a < <br /> PHASE II GROUT IN&PECTIO PHASE III/FINAL NSPEC'TI - �� <br /> INSPECTION BY DATE I INSPECTION BY DATE r E <br /> e <br /> CALL FOR A GROUT INSPECTION PRIOR -TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 "At, 5/731X <br />