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_ .JOAQUIN LOCAL HEALTH DISTRIC" <br /> Foe OFFICEFUSE: 160 :. Hazelton Ave. , Stockton, Ca7lvo. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. j- `J- <br /> 42 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /bb/ <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 Joaluin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distrizt. <br /> JOB ADDRESS/LOCATION / 60 d CENSUS TRACT <br /> Owner's Name t.1.9i I i �< >> ! 1 <br /> ' r 1 1 C� r, ;� n � �n Phone <br /> Address ; .. City <br /> Contractor's Name License # /</� i7 , Phone <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /—] <br /> PUMP INSTALLATION / J PUMP REPAIR /h/ PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ 0(1 <br /> INTENDED USE TYPE OF' WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing (n <br /> Irrigation Gravel Pack Depth of Grout Seal , <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor " 01 ! ! r' <br /> Type of Pump i, : H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done q f <br /> vv <br /> DESTRUCTION 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 DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric't 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 my knowledge and belief. <br /> SIGNED TITLE <br /> . DRAW-PLOT PLAN ON 'REVERSE SIDE <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE -Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR S C N PHAS • III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY GZM6 DATE <3Lr <br /> CALL F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI t. <br /> E H 1426 7/72 1M v4`x�- <br />