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t <br /> f Q . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t�OL.,OFFICE USE: U� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued �-,76,-- <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 trade in compliance with San Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Ltealth District. <br /> JOB ADDRESS/LOCATION= i ICI CENSUS TRACT <br /> Owner's Name .�/`t E1.S� � - - --- -- Phone �; -71 <br /> i <br /> Address ? City ' <br /> Contractor's Name � � -� �� License # Phone-)qJ TI'3 <br /> TYPE OF WORK (Check) : NEWiWELL IC4---SEEPEN / / RECONDITION I ! DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> Industrial }. .able Tool Dia. of Well Excavation <br /> 4_--Mmestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven --Gauge--of- Casing E] - <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information n <br /> 4 PUMP INSTALLATION: Contractor <br /> h Type of Pump H.P. <br /> PUMP REPLACEMENT: / T State Work Done <br /> f PUMP 'tEPAIR: % State Work..Done <br /> ,DFgTRUCTION 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 /> i after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL 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 <br /> --- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY :. DATE � <br /> ADDITIONAL CO�AIENTS: i'1 <br /> PHASE 11 GROOT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE -sjp -]� INSPECTION BY DATE Y-.fid <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />