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SAN JOAQUIN LOCAL HEAiJTH DISTRICT + <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APP CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 711 <br /> +� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2. O Tri <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 /> t <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner's Name I Phone <br /> Address . p' Y © Vy 0.? —_ City .M&n ti 0, �1 <br /> Contractor's Name License _7Z Phone 0VE 3 <br /> TYPE OF WORK (Check) : NEW WELL% / DEEPEN / f RECONDITION /_-7 DESTRUCTION /-7 F <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other /-7 <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 Cable Tool Dia. of Well Excavation / tip <br /> Domestic/private X Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 111 <br /> Other Rotary Type of Grout �+ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .pEST_R_UCTION 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 oe <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTNUT,USE ONLY <br /> PHASE I <br /> APPLICATION ACC DATE _" <br /> ADDITIONAL COMMENTS: -' T <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY � / Q ._"y) INSPECTION BY TE +167-12— <br /> DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 V4/72 1M <br />