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rr <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <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 Issued ? 3l-,73 <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 San Joaquin Local Health District. 1 <br /> JOB ADDRESS/LOCATION CENSUS j2 ?'�RACT I <br /> - -- -� <br /> VV <br /> Owner's Name Phone �I <br /> Address szoa �. __..,..� city - <br /> P--o I� <br /> Contractor's Name 4d rj License # 103 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /—T DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR Y PUMP REPLACEMENT /- <br /> Other <br /> .IM 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER G <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation IM df <br /> Domestic/private Drilled Dia. of Well Casing <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 il <br /> I. PUMP INSTALLATION: Contractor <br /> Type of Pump IH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br />, ,EESTRUCTION 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 Localj�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 /> 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 /> SIGNED _ -y �m_ (�o r• .�, �.c r v hl� • TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I s <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: IM i <br /> PHASE II RUT INSPECTION PHASE II F NAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE //,— <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ef <br /> E H 1426 N 7171 i m <br />