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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr"01'IILE USL: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Y- 96 <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �j (Complete In Triplicate) <br /> Application is hereby .nade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. - Thin application is made in compliance' with San Joaquin <br /> County Ordinance No. 1862 an`d the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT , --�� <br /> Owner's Name £ l �0 . -_-- f „ Phone <br /> Address <br /> CityAL�� <br /> Contractor's Name 3 License Phone ' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other' / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY \ <br /> SEWAG. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. I Cable Tool Dia. of Well Excavation <br /> Domestic/private a Drilled Dia.- of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation �� Gravel Pack Depth of Grout Seal e2 -� <br /> Other '�. Rotary Type of Grout „- ---_ <br /> I e Other Other Information ' t� <br /> PUMP INSTALLATION: Contractor <br /> Type of'Pump H.P. <br /> P LIMP REPLACEMENT: / f State Work Done <br /> I <br /> PUMP TtEPAIR: :State Work 4D one <br /> ,DFQTRUCTION 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 well and notifythem before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> e. 2t <br /> TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPkPgMENT USE ONLY <br /> PHASE I /-- <br /> APPLICATION ACCEPTED . BATE - <br /> ADDITIONAL COMMENTS <br /> PHA E II GROAT INSPECTION V PHASE I FINAL INSPECTION <br /> INSPECTION BY �p�.� DATE. 7 Z- bINSPECTION BY o DATE h- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND -FINAL INSPECTION. <br /> E H 1426 q/731M <br />