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,<r VZ <br /> SAN 10AQUiN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' . � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued47re <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 Sail Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District.'^ <br /> JOB ADDRESS/LOCATION 9 g22-? ,�� ,� „--- �_e _ . CENSUS TRACT <br /> Owner's Name ki Phone <br /> Address -------.3_�� �7 ---_ _4k>4 ,�?c7 City ��SG.�YC�►, <br /> Contractor's Name '"- License 11 of Phone <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /_/ PUMP REPAIR/ / PUMP REPLACEMENT /7T, <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 A3 <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Donee <br /> PUMP UPAIR: / / State Work Done - - <br /> .DFsTRUCTION 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 to the best of my knowledge and belief. <br /> SIGNED a. <br /> 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 I I SPECTION <br /> INSPECTION BY DATE INSPECTION4 PATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />