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I <br /> j L <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OF 1 ICE USE:: 1i 01 E. Hazelton Ave. , Stockton, Calif. <br /> I <br /> Telephone: (209) 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s 71P <br /> THIS PERMIT EXPIRES 1 ::YEAR FROM DATE ISSUED Date Issued -1l-7r t <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to const7'uct <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 /> a <br /> JOB ADDREsS/LOCATION 3 0 ` /�aAl A 0 CENSUS TRACT <br /> Owner's Name 42 7:o Phone 6 fJ <br /> n ' Citl r�o A/ � L�/A- <br /> Address / ,3 (7 a Y <br /> j� License #,? s'-1 6/ Phone 46 <br /> Contractor s Name <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/-7 RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> ` Othe-r / / <br /> DISTANCE TO NEAREST: SEPTICJTANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE �TYPE OF _WELL 4 <br /> Tndustrial� , Cable Tool Dia. of Well Excavation <br /> Domestic/private f Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation it Gravel Pack Depth of Grout Seal <br /> Lather Rotary Type of Grout <br /> -- 11 Other Other Information <br /> PUMP INSTALLATION: Contractortee- <br /> ._.. - c, <br /> Type of rump a�� H.P. <br /> E PUMP REPLACEMENT: State Work Done <br /> k"`PUMP-TtEPAIR /l / StateAWork -Done <br />� t <br />+ DF9TRUCTION 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 />`.1 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 /> + TITLE <br /> SIGNED - <br /> ,} (DRAW PTAVf PUY ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE J �� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION '' P 22!��I/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATF _ <br /> CALL FORA GROUT INSPECTION PRIOR-TO GROUTING AND FINAL INSPECTION. /7 <br />