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!/ SAN JOA UIN LOCAL HEALTH DISTRICT Qc) copy , <br /> ror.6FFICE USL. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466--6783 <br />€ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 s- <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued/j <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joo-a-q-uin Local }tealth District. <br /> JOB ADDRESS/LOCATION„! Q I L�;t7 ¢/l�� /9j � -CENSUS TRACT <br /> j Owner's Name Phone <br /> Address City <br /> Contractor's Name License #,1h.1Phon _. 6l <br /> TYPE OF WORK (Check): NEW WELL _/Ff DEEPEN /—]: RECONDITION /_7 DESTRUCTION f_7 <br /> PUMP INSTALLATION REPAIR 1_/ PUMP REPLACEMEI3T /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA&VK SEWER LINES PIT PRIVY r- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done 4 <br /> ;pFgTRUCTION 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 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 /> FOR DEPARTMENT USE ONLY <br /> PHASE INkN� <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: Q It <br /> PHASE II GROUT INSPECTION PAkS.E I FINAL INSPECTION <br /> INSPECTION BY DATE CI-419_ji:16 INSPECTION BY DATE Xp <br /> CALL FOR AqkDUT INSPECTION PRIOR, TO-GROUTING AND FINAL INSP ION. <br /> E H 1426 5/731.M <br />