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Jj <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFOr.:OFrICB USt;: 1601 E. Hazelton Ave,, Stockton, Calif. r . <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELT. CONSTRUCTION OR PUMP PERMIT Permit No. 3- 1/ 5,4a <br /> THIS PERMIT EXPIRES 1 'YEAR FROM DATE ISSUED Date Issuedj-.27-Z_7 <br /> (Complete In Triplicate) ' <br /> ct <br /> Application is hereby wade to the San Joaquin Local Health District for a permit to constm Jo <br /> and/or install the work herein described. ' This application is made in compliance with S'an oaquin <br /> County Ordinance No. 1852 and the Rules and Regulations o the San Joaquin Local health ;District. <br /> JOB ADDRESS/LOCATION � `� " r '/ CENsys TRACT <br /> Owner's Name '� 1 c�v - Phone <br /> City ' Sites <br /> Address ` <br /> License # 2 6 phone 'd, p <br /> Contractor's Name � <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / RECONDITION DESTRUCTION DESTRUCTION /TT <br /> PUMP INSTALLATION_/ / PL'I� REPAIR PUMP REPLACEMENT <br /> / / <br /> Other' / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> . Domestic/private E Drilled Dia. of Well Casing T <br /> Domestic/public Driven Gauge of Casing <br /> , <br /> Gravel. Pack Depth of Grout Seal <br /> Irrigation <br /> Other I Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor . <br /> H.P. <br /> Type of Pump ` _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> } PUMP `tEPAIR• _ State Work Done <br /> DFqTRUCTTON 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 Healthl' District <br /> and the State of California pertaining to or regulating wel.l ''construction. Within FIFTEEN DAYS <br /> after completion of my work an 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 m know ed an belief. ` <br /> � ITLE <br /> SIGNED <br /> PLO PLAN ON RE RSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL. COMMENTS: <br /> F PHASE II GROUT. INSPECTION PHASE III/FINAL NSPECTI N <br /> INSPECTION BY ATE // <br /> DATE „/ ' <br /> +� INSPECTION BY ` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ,..mac <br /> 5/7.31M <br />