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SAN JOAQUIN LOCAL HEALTH DISTRICT x ' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: '''����09)- 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION -OR'-PtLMP' PERMIT Permit No;. <br /> THIS PERMIT EXPIRES' 1 YEAR FROM DATE ISSUED Date Issued to y <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 Na: 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION i! <br /> CENSUS TRACT I� <br /> Owner's Name �j i <br /> PhoneG , <br /> Address f1 s <br /> o all <br /> City ;� s <br /> Contractor's Name License # Phone I, <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN _ i <br /> RECONDITION /� DESTRUCTION /7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other /-7 — -- <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER I' { <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS; <br /> Industrial ,/ Cable Tool Dia, of Well Excavation ¢ ,j ' <br /> Domestic/private Drilled Dia. of Well CasingC } <br /> Domestic/public Driven <br /> Gauge of Casing I; <br /> Irrigation Gravel Pack Depth of Grout Seal Z-1 <br /> Other Rotary Type of Grout n <br /> Other Other Information <br />;, UMP INSTALLATION: Contractor !! <br /> --- Type of Pump <br />� <br /> H.—P—. <br /> PUMP REPLACEMENT: / J State Work Done <br /> G <br /> PUMP REPAIR: / / State Work Done <br />.PESTRUCTION OF WELL: Well Diameter <br /> ' -- — Approximate Depth ! �� <br /> Describe Material and Procedure <br /> II <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local HealthiDistrict <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 Healthi+bistrict 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 �i <br /> PHASE I <br /> MY DEPARTMENT USE ONLY <br /> i <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION � <br /> PHASE IIIJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTI PRIOR TOG © IN� AND .FINAL INSPECTION. 11 <br /> E H 1426 - �/ � 7/72 1M <br /> ``f <br />