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SAN JOAQUIN LOCAL 'IIEALTH DISTRICT -i <br /> FOR 0 ) ICE USE: 1601 E. Hazelton Ave. , -.Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �Z <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 /> JOB ADDRESS/LOCATION t CENSUS TRACT <br /> E <br /> Owner.'s Name41 A4 Phone <br /> Address � ��..�� j � �I�7i�� ? City ; z�­-v . <br /> Contractor's Name ��� at•� License 4� Phoneme? -r?�?� <br /> TYPE OF WORK (Check) NEW WELL /T/ DEEPEN '/ / RECONDITION /_/ DESTRUCTION /? ! <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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing LA <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other-Information <br /> fi <br /> PUMP INSTALLATION: Contractor ( <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP:-REPAIR:.r. _�-t--� / State--work Done- <br /> .DESTRUCTION OF WELL: Well Diameter. Approximate Depth <br /> Describe Material and Procedure <br /> I4 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 PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PMS I INAL INSPECTIO <br /> E -INSPECTION BY INSPECTION BY ( DATE 2D -7 Zr <br /> f CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - <br />`' <br /> 4/72 1M <br /> E H 1426 <br />