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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE_ O1'FIU'3 USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - 4�4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Satz Joaquin Local Health District. k. <br /> �G( J , <br /> JOB ADDRESS/LOCATION JS 7 ' ✓�✓L h CENSUS TRACT <br /> Owner's Name Phone <br /> Address City v� <br /> Contractor's Name ' License # Phone ' „ <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other P /. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C3� <br /> SEWAGE DISPOSAVeIELD CESSPOOL/SEEPAGE PIT OTHER (]� , <br /> ra <br /> INTENDED USE TYPE OF WELL t:yd. t CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dial of Well Excavation 1 <br /> Domestic/private ! Drilled a of Well Casing i <br /> Domestic/public 1 Driven Gauge of Casing G <br /> Irrigation I Gravel Pack Depth of Grout Seal I <br /> Other �� Rotary Type of Grout 1 <br /> 1 Other #` Other-lnformat.ion T <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump 1 '+� # H.P. -- <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP 'tEPAIR: / / State Work Done <br /> // roxi�ate De th <br /> ,DFRTRUCTION OF WELL: Well Diameter # � App # <br /> Describe Material and Procedures it <br /> I hereby agree to comply wi all laws and regulations of thelSaniJoaquin Local Health District <br /> and the State of California pertaining to or regulating wellfcorist:ruction. Within FIFTEEN DAYS <br /> F after completion of ray work onja new well, I will furnish theSan3oaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before-pattir#g the well in use. The above <br /> information is true to the besi of my knowledge andel lief <br /> SIGNED ! !TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY E� A DATE ? <br /> ,, <br /> ADDITIONAL COINMENTS: Gc� <br /> PHASE II GROUT INSPECTION PHASE III/FINAL PECTION <br /> INSPECTION BY DATE INSPECTION BY f DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5�731M <br />