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i r v <br /> /✓ SAN JOA UIN LOCAL HEALTH DISTRICT <br /> Q <br /> x.01'. Oi'11CI; USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -,_— Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nn-;;U-_S--3..J-0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued jj.,i >3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a Permit to censvru( t <br /> rind/or install the work herein described. ' This application is made in compliance wLt:h San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations �t e�San Joaquin Local. Ihalth District. <br /> R S <br /> JOB ADDR /OCATIUiI 11` J [ �� .� - CENSUS TRACT b <br /> Owner's Name �.� (�1 `[� 1 Phone <br /> Address <br /> City G3 <br /> Contractor's Name License JZ one -7 V <br /> TYPE OF WORK (Check) : NEW WELL RECONDITION /-7 DESTRUCTION /-7 i <br /> PUMP INSTALLATION / / PUMP REPAIR /-/ PUMP REPLACEMENT /7 i <br /> Other <br /> 1 <br /> [DISTANCE TO NEAREST: SEPTIC TAiJK _ SEtdER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �1E <br /> Industrial moble Tool Dia, of Well Excavation <br /> _&mestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing G I <br /> � rigation Gravel Pack Depth of Grout Seal <br /> -— Other Rotary Type of Grout ! <br /> Other Other Information <br /> P01 INSTALLATION: Contractor ; <br /> Type of Pump H.P. ; <br /> E <br /> PUMP REPLACEMENT: / / State Work Done fi <br /> PUMP '+.EPAIR: i <br /> / / State 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 /> [:ELL URILLERS 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 PIAT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY — <br /> 1'liASI; I - <br /> ,EFi IACATTON ACCEPTED BY DATE /!3 <br /> ADDITIONAL COMMENTS: <br /> : <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE/0 _ INSPECTION BY /J DATE <br /> CALL DOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1425 5/731x1 <br />