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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a � $ �' <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued. {,-Y-2-_; <br /> 11 - (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 /> .TOB ADDRESS/LOCATION ! aG CENSUS TRACT <br /> Owner's Name Phone <br /> i <br /> Address f 2 <br /> Contractor's Name License # Phone uG,v 2,p.19 , <br /> TYPE OF WORK (Check) : 'NEW WELL / / DEEPEN / / RECONDITION /_ DESTRUCTION /? <br /> PUMP,� INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> O th I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER : <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation „s <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ; <br /> Irrigation Gravel Pack Depth of Grout Seal Q; <br /> Other Rotary Type of Grout <br /> .� Other Other Information •% <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / '. State Work Done <br /> PUMP REPAIR: J % State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> �N <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 /> I� <br /> SIGNEDTITLE <br /> (DRAW PLOT ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE �3 <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 7/72 1M <br />