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SAN JOAQUIN LOCALtIHE-ALTH DISTRICT <br /> FOE': <br /> USE; 1601 E. Hazeltoif`Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES ], YEAR FROM DATE ISSUED Rate 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 axid- the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ d�!/r( G� J oe;✓ CENSUS TRACT $ <br /> 1 / C� <br /> s am ?,:2d er b�-P Phone <br /> AddressQ -� <br /> City . . ,= <br /> r , � License �������u'phone <br /> � s3��s <br /> Contractor s Name _ _ ,..i <br /> E _ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION /—/ DESTRUCTION /,T <br /> PUMP INSTALLATION / / PUMP REPAIR / I p REPLACEMENT I��T <br /> Other I / <br /> DISTANCE TO NEAREST: SEPTIC TANK Igge 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 z <br /> Domestic/private Drilled Dia. of Well Casing <br /> el <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. ` <br /> Z( Rotary__,,--.Type of Grout <br /> Other ---. - <br /> Other Information <br /> PUMP INSTALLATION: Contractor r'© <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done } <br /> �;•„ rusv t-cc�C� <br /> ° PUMP 'tEPAIR: State ork Done <br /> a <br /> DFCTRUCTION 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 /> i 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 ab <br /> ove <br /> information is true to the best of my knowledge and belief. <br /> TITLE + <br /> SIGNED .v — <br /> (DRAW PLOT PLAN ON REVERSE',SIDZ,) <br /> FOR DEPARTMENT USE ONLY <br /> A <br /> PHASE I <br /> - <br /> APPLICATION ACCEPTED BY DATE <br /> '`' ADDITIONAL CONIZ ENTS: <br /> PHASE II GROUT INSPECTION PHASE UI/FINAL INSPECTION <br /> INSPECTION BY DATE . INSPECTION BY DATE f <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> 5/73 _1 <br />