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- (/l3 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> THIS PERMIT EXPIRES 1.YEAR FROM DATE ISSUED Date Issued <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 Regulation's of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION b0� rf CENSUS TRACT <br /> tr , V ` <br /> Phone <br /> Owner's Name LjZ421�If <br /> --low <br /> � � I city - <br /> Address <br /> Contractor's Name <br /> License #/Z-7�Phone,3 <br /> t <br />� I � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /� RECONDITION / PUMP CTION <br /> /�]� <br /> PUMP INSTALLATION � PUMP REPAIR PUMP REPLACEMENT <br /> Other '/ / <br /> i <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> s INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> - rivate Drilled Dia. of Well Casing <br /> Domestic./private <br /> Domestic/public Driven Gauge of Casing <br /> ��. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout `n <br /> Other Other Information V <br /> t � <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type4of Pump <br /> PUMP REPLACEMENT: Mate Work Done . <br /> 4PUMP REPAIR: / / State Work Done ') <br /> ESTRUCTION OF WELL: Well>.Diameter <br /> 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 /> land the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, lthemwill <br /> beforefurnish <br /> puttingSan <br /> theowellninouse.cal HeThehaboverict a <br /> WELL DRILLERS REPORT of the well and notify <br /> information is true to the best of my knowledge and belief. <br /> TITLE <br /> ISIGNED <br /> 4 F (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> [ PHASE I DATE J IS- <br /> APPLICATION ACCEPTED BY ` <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE 7✓/ �� <br /> INSPECTION BY ,� DATE r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> ` E H 1426 <br />