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(� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR V2LL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z 2 <br /> 7/_ /�7P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .3--?9�r� <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/ ON �� i j I CENSUS TRACT <br /> Owner's Nam Phone <br /> Address City <br /> f /� <br /> Contractorws Name kwy License Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / J RECONDITION /_/ DESTRUCTION /_7 r y. <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ) <br /> SEWAGE DISPOSAL FIELD -� CESSPO L/SEEPAGE PIT OTHER IV <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool Dia. of Well- Excavation 0 '� T <br /> Domestic/private X Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ c <br /> Irrigation Gravel Pack Depth of Grout Seal -� <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor s <br /> Type of Pump ` H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> .PUMP REPAIR: / / .._State Work Dane <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 t ue to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> { RAW PLOT PLAN ON REVERSE SIDE) , <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY DATE '.�7-T <br /> ,. -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE r,�> ! rte " INSPECTION BY W DATE -/--7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />