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f <br /> •, � , �'D SAN JOAQUIN ,LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: r 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) : 466-6781 <br /> APPLICATION FOR WELT. `CONSTRUCTION -OR PUMP PERMIT Permit No.HJT ;�S cf-) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.- .� j <br /> (Complete' In Triplicate) <br />�,.:Appl.ication is hereby made totthe 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 andLthe Riiles 'and Regulations of the" San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address ) City _ <br /> Contractor's Name License #1"7,6 2 29Phonegj . <br /> TYPE OF WORK (Check) : NEW WELL /k_T DEEPEN /_7' RECONDITION 7 4DESTRUCTION . <br /> y _ 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 Cys' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of Well Excavation <br /> __ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ?i Driven Gauge of Casing Z <br />° Irrigation :1 Gravel Pack Depth of Grout Seal ' r <br /> Other TI Rotary Type of Grout <br /> Other. Other Information <br /> t PUMP INSTALLATION: Contractor <br /> Type 'of Pump r H.P..y7, -- <br /> PUMP REPLACEMENT: / / State Work•Done <br /> PUMP REPAIR: / / State Work Done T <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <br /> I,hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State •of California $e.rtaining 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 /> J 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 /> rSIGNED T TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F EPA USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP BY DATE /--L/ <br /> ADDITIONAL COMMENTS:, <br /> PHASE IV GROUT .INSPECTION PHAS III FITAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE - C <br /> CALL FOR A GROUT .INSPECTION PRIOR TO .GROUTING AND FINAL INSPECTION. .. -- <br /> E H 1426 7/72 1M �• <br />