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SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOR 0 VICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ; <br /> Telephone: (209) 466-6781. X <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3- s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'Date 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 and the Rules and Regulations of the San Joaquin Local Health District. ! <br /> JOB ADDRESS/LOCATION ! _fl �� _ CENSUS TRACT <br /> Qo-� 41"- <br /> Phone /ff <br /> Owner's NameQ <br /> City <br /> Address <br /> Contractor's Name License # Phone 7 7 1 <br /> TYPE OF WORK :(Check-).: NEW WELL /-7 DEEPEN / / RECONDITION DESTRUCTION — <br /> �! ',PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEARE EPTIC TANK S LI S PIT PRIVY <br /> E SEWAGE DISPOSAL FIELD. CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL F CONSTRUCTION SPECIFICATIONS -46 <br /> Industrial - -- Cable 'Tool Dia. of Well Excavation <br /> Domestic/private Drilled ` Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> fOther, Other Information <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump 1H.P. <br /> PUMP REPLACEMENT:~ State Work Done <br /> 11 welch <br /> PUMP REPAIR: / / State Work Done <br /> i <br /> 1 <br /> i ,DESTRUCTION OF WELL: Well Diameter _' r Approximate Depth <br /> Describe Material and Procedure <br /> E <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 /> 4 information is true to the bes of my knowledge and belief. <br /> 114 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> 1 PHASE I DATE <br /> APPLICATION ACCEPTED BY 0 - ; <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> f <br /> 4 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI N. <br /> J �7172 1M - <br /> E H 1426 <br />