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SAN JOAQUIN LOCAL HEALTH DISTRICT oto <br /> 0 . O FICE <br /> USE: 1601 E. Hazelton Ave. , Stockton, Calif. p5 <br /> i I 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/b <br /> i , (Complete In Triplicate) <br /> Applicatiozi 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 ,ana the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. CENSUS TRACT <br /> 16 <br /> Owner's Name Phone <br /> Z I I L� <br /> Address # City (Fac.A�p� <br /> EQ LA i P. <br /> Contractor s Name License # Phone <br /> TYPE OF WORK (Check) : NEW.WELL / / DEEPV_;/ / RECONDITION / / DESTRUCTION /_7PUMP. INST`ALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTICTANKSE INES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD W� CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public l _ Driven Gauge of Casing <br /> Irrigation 3 Gravel Pack Depth of Grout Seal <br /> Other }. Rotary Type of Grout <br /> Other Other Information q <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. s <br /> PUMP REPLACEMENT: / / State Work Done , <br />__RUMP,�.AEPAIR: t _ , /_/_ :S.ta-te..-Work.-Done <br /> ,DFgTRUCTION 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 hell and notify them before putting the well in use. The above <br /> inform io s truetth-e best of my knowledge and belief. <br /> i <br /> SIGNE - E'er � TITLE-- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BY CJI, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE _,;I_�/FIN4 INSPECTIO <br /> INSPECTION- BY DATE INSPECTION BY E /?,/77 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H I47_h e /72,-091 <br />