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SAN JOAQUIN LOCAL HE �],I�TSICT_ <br /> i Tfli.:O1TICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Tele 20 466--6781 ' � " e- <br /> hone: 9) <br /> Telephone: � c.G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT,7; rYP�mlllda, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �41 7 <br /> (Complete In Triplicate) <br /> rrt 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 r_ �. _ �g�r-m i r - CENSUS TRACT <br /> Owner's Name �>jPhone 4� 3 " s-3 o / <br /> i <br /> Address S cd e City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / UMP REPLACEMEN /� <br /> Other / / � — — <br /> DISTANCE TO NEAREST: SEPTIC T&NK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT Ff, OTHER <br /> INTENDED 'USE ,, TYPE OF WELL � CONSTRUCTION SPECIFICATIONS <br /> Industrial ` Cable Tool Dia of Well Excavation <br /> r t <br /> r <br /> Domestic/private Drilled ° 1i3ia.�of Well Casing <br /> Domestic/public Driven Gauge of; Casing- <br /> Irrigation " Gravel Pack Depth of, Grotit Seal <br /> Other i Rotary Type"of-Grout' <br /> Other Other Information1t <br /> PUMP INSTALLATION: Contractor <br /> t t Type of Pump <br /> PUMP REPLACEMENT: /I / State Work Done <br /> PUMP UPAIR: / / State. Work Done r <br /> T 1 t <br /> ,DFSTRUCTION OF WELL: Well Diameter'i �t; �r1 #r Approximate Depth <br /> scribe 'Material and-Procedure 1 ( r t ve <br /> PL4C P ±b <br /> V4 Lc <br /> I hereby agree to comply with all laws` arid '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 willlfurnish the San Joaquin Local Health District a <br /> WELL,DRILLERS REPORT ofl.the well and notify them �efore putting the well in use. The above <br /> i' information is true to the best of my knowledge and belief. <br /> SIGNED <br /> u <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT: USE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPTED .BY DATE17,1�71114-- <br /> ADDITIONAL <br /> COMMENTS: <br /> t PHASE II GROUT INSPECTION PHASE ,III/FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE <br /> - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> t E H 1426 5/731.M <br />