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SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ,� �r <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S4 kJ <br />' THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued ,6�-fr_ � <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 Sang Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> �-- CENSUS TRACT ( <br /> LOwner's Name l� l T Phone 3 ` - 7 2� <br /> a j <br /> Address _ � City Lp <br /> Gontractor's Name <br /> �S _ License /3jZ-�3Phone7�5 "4� <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN /_/ RECONDITION /_ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> j SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Tool Dia. of Well Excavation <br /> estic/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 C <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /7./ State Work Done <br /> _ a <br /> { PUMP REPAIR: / / State Work Done <br /> 4 <br /> ESTRUCTION 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 is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE2401ZV144_e _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III FINAL INSPECTION <br /> -71 <br /> ti <br /> INSPECTION BY r DATE 3 r INSPECTION BY DATE 7 <br /> CALL FOR A GROUT..INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E'H 1426 7/72 IM <br />