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J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.73)"520 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,-;-,,L7,5 <br /> (Complete In Triplicate) <br /> Applicatio s ereby 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 Joaqui <br /> County Ordinance No. 186 and he Rules endgul�s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION'�o C� CENSUS TRACT <br /> Owner's Name_ 5 Phone 36 9-W?o 63 <br /> Address s City �c .. <br /> Contractor's Name Licens% 6-��3a�Phone J92!- 6y0 <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION /- DESTRUCTION /-7 <br /> PUMP INSTAL kION / / PUMP PAIR ��:P REPLACEMENT /7 <br /> Other / / <br /> dd <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 /> _ }olnestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ,r/Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. /s Ham <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 11 to the best of my knowledge and belief. <br /> SIGNED �G• 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 PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE ".,INSPECTION BY DATE 4-/ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 1426 702 1M <br />