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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE SE: /"" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No:J3_ irj <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued ,- 2-r 73 <br /> (Complete In Triplicate) It <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 /> JOB ADDRESS/LOCATIONF CENSUS TRACT i <br /> Owner's Name <br /> Phone <br /> Address Z 2 17 A 4 , ocgt City �. <br /> Contractor t s Namey , ��.,�, License 0� j 7 3 Phone <br /> TYPE OF WORK (Check): NEW WELT. /_7 DEEPEN ~/�7_ RECONDITION f;_/1 DESTRUCTION /? <br /> PUMP INSTLATION PUMP REPAIR / I PUMP REPLACEMENT /�T <br /> ALj <br /> Other l/ / <br />[ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public +:i Driven Gauge of Casing <br /> Irrigation ;t Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> �1 Other Other Information <br /> ,1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i PUMP REPLACEMENT: / / State Work Done 10 <br /> r. PUMP. REPAIR.., •,./>St State Work Done <br /> F <br /> , ,DESTRUCTION 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 TITLE <br /> (DRAW PLOT LAN ON REVERSE SIDE <br /> FDR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE 7—, �2 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUV INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY iDATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI . 7 <br /> E H 1426 ''' <br />