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At <br /> Y y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z ,7}:1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. ' -- 7 <br /> 17 <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 Joaquin Local Health District. , <br /> r� 7 <br /> JOB ADDRESS/LOCATION aS / CENSUS TRACT <br /> . f <br /> Owner's Name + <br /> Phone � <br /> Address City <br /> Contractor's Name /_ � <br /> License i� ? Phone <br /> TYPE OF WORK (Check): NEW WELL / J DEEPEN /_7 RECONDITION /`7 DESTRUCTION /_7AL <br /> PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT fjf i <br /> Other / / •`-� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p <br /> INTENDED USE TYPE OF WELL �a <br /> CONSTRUCTION SPECIFICATIONS �f <br /> Industrial Cable Tool Dia. of,Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casings <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 P A H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR. <br /> / / State Work`Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 <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 ay" <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 /> 1 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P III FINAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />