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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: KAPPLICATION <br /> 1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> PERMIT EXPIRES I 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 Regulations of the San Joaquiri' Local Health District. <br /> JOB ADDRESS/LOCATION d '2- CENSUS TRACT — <br /> Owner's Nares , Phone ? <br /> ------ <br /> Address �1_ -- c�, City <br /> contractor's Name License fvjr3 zO Phone`f 3 <br /> E <br /> TYPE.-OF WORK (Check): NEW WELL /;'DEEPEN /? RECONDITION. / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 4 <br /> DI5TANCE TO NEAREST: SEPTIC TANK �U SEWER LINES PIT PRIVY y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a Tool Dia, of Well Excavation' ., _r _ <br /> Domestic/private Drilled Dia. of Well Casing�__ <br /> Domestic/public _ Driven Gauge of Casing ; <br /> o-- *f�rrigation Gravel Pack Depth of Grout Seal <br /> Other Rot�'ary Type of Grout _ <br /> Other Other Information <br /> PUNK' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> c _ <br /> PULP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 c� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> f PHASE II GROUT INSPECTION PHASE 3I4/FINAL INSPECTION <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 />