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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6.787. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS 'PERMIT tEYJ. IRES 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 Sn� Joa uin Local Health District. <br /> JOB ADDRESS/LO TION alty CENSUS TRACT <br /> J/ <br /> Owner's Name lGt Phone <br /> Address . . , City <br /> Contractor's Name License #/241jj_VPhone g13 If 41 1.3 <br /> TYPE OF WORK (Check): NEW WELL /YU DEEPEN /�/ RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION /C/ PUMP REPAIR f / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: , SEPTIC TANK-_-' SEWER LINES PIT PRIVY g <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - <br /> Industrial Cable Tool Dia, of Well Excavation ` <br />_____,L,Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other yRotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump 1A 4 s7a 77-1*1H.p. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP REPAIR: / / State Work Done j <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 welliand notify them before putting the well in use. The above <br /> information is true to th best of my knowledge and belief. <br /> SIGNED C i co 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 /> PHASE II GROUT INSPECTION PHASE III.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 Ioe i err 7/72 1M Ca <br />