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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION.-OR PUMP PERMIT Permit No. 12-- S <br /> THIS PERMIT EXPIRES 1 YEAR FROM .DATE 'ISSUED Date Issued- <br /> (Complete In Triplicate) ; <br /> Applicatio is,here y-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 Ru and, Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �Y CENSUS TRACT <br /> Owner's Name' j^ Phone <br /> .Address.. City . <br /> Contractor's Name License # Phone . 3 <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN /'77'-RECONDITION / DESTRI3CTION %r <br /> PUMP INSTALLATION / / PUMP REPAIR -/_/ PUMP REPLACEMENT • <br /> Other /7 r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESS� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD . CESSPOOL/SEEPAGE PIT, - OTHER <br /> z 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 '.' A <br /> PUMP INSTALLATION: Contractor ,� ► <br /> ,. Type of Pump H.P. <br /> .PUMP REPLACEMENT: 1--C/ State Work Done ���,r��• _�� � <br /> PUMP REPAIR: / / State Work Done <br /> - A 4 <br /> ,pESTRUCTION 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 true t the best of my knowledge and belief. <br /> SIGNED TITLE zL 1_� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> -.-_ FOR DEPARTMENT' USE ONLY <br /> PHASE I <br /> APPLICATION_ CE <br /> ACP_TEDTBY DATE �O Z <br /> .ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FTNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426' ' 4/72 1M <br />