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FOR OFFICE USE• JOAQUIN LOCAL HEALTH DISTRICT <br /> 1604-. Hazelton Ave. , Stockton, Cal <br /> l I <br /> Telephone: (209) 466-6781 FI� ECDPY <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITrmit No.IEZ�4ko <br /> ' THIS PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued <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. <br /> JOB ADDRESS/LOCATION ` ? C <br /> r' <br /> CENSUS TRACT <br /> r <br /> Owner's Name , <br /> Address 2 Phone/ <br /> r � <br /> Ir <br /> City <br /> f Contractor's Name <br /> License OWU Phone3 S <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN / / RECONDITION /�' DESTRUCTION /� <br /> PUMP INSTALLATION /7/ PUMP REPAIR L/ PUMP -REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK. <br /> 5EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS€POOL/SEEPAGE PIT <br /> OTHER f <br /> INTENDED USE TYPE OF WELL <br /> Industrial r CONSTRUCTION SPECIFICATIONS pt <br /> Cable Tool Dia:; of We11 Excavation 'V <br /> _ Domestic/private Drilled . v <br /> Domestic/public r ..Dia: of Well Casing <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack <br /> then- _ — - - _----Depth of Grout_Seal <br /> Rotary Type of Grout - <br /> Other - Other Information <br /> PUMPINSTALLATION: Contractor e <br /> Type of Pump s <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: 17 State Work Done <br />,DESTRUCTION OF WELL: Well Diameter <br /> —` <br /> Describe Material and Procedure `',�` Approximate Depth ---•-------- <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 notify them before 'Putting the well in use. The above <br /> information is true to the est of my knowledge and belief, <br /> SIGNEDL.e� <br /> TITLE !� <br /> (n L T PLAN ON REVERSE SIDE <br /> PHASE I DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL °COMMENTS: DATE ', . <br /> INSPECTION BY <br /> PHASE II P T PHASE II FINAL INSP C ON <br /> AT INSPECTION BY <br /> DATE d <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 <br /> 7/72 1M <br />