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J / SAN JOAQUIN -LOCAL HEALTH DISTRICT j <br /> FOR OFFICE USE: // 1601 E. Hazelton 'Ave;,' Stockton; Calif. <br /> Telephone: (209) 466--6781 <br /> i <br /> APPLICATION FOR WELL" CONSTRUCTION OR PUMP PERMIT Permit No: zj-,2//4J <br /> i <br /> THIS'PERMIT`EXPIRES 1 YEAR FROM DATE ISSUED Date Issued G -i 9-� I <br /> (Cbmplete' In Triplicate) <br /> Application.'is.,hereby';mad"e`�to the "San `Joaquin Local Health District 'for `a'per'mit to construct II� <br /> and/or install the work herein described. 'This'.application is made in compliafice: with San Joaquinl, <br /> County, Ordiriance 'No. 1862"'-and: t`h 'Rules and Regulations of the San Joaquin Local Health. District: <br /> a <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT i <br /> Owner-'aN Name - , :€> : . ...c. �,., <br /> Phone <br /> Address Y 1 <br /> . : <br /> Contractor's Name - I License # Phone <br /> TYPE OF WORK (Check) : NEW WELL //0 DEEPEN /_/ RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> i <br /> DISTANCE TO NEAREST: ' SEPTIC TANK' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . ' Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Other Gravel <br /> Type of Groixt <br /> Other . Other Information i <br /> 1 <br /> k <br /> PUMP INSTALLATION: Contractor' At Lt <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP REPAIR; //--State_.Wo.rk Donee <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 Localt"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 /> , <br /> SIGNED " 4TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID!�", <br /> R`DEPARTMENT USE ONLY <br />'PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PS II AL INSPECTION <br /> INSPECTION BY DATE �, INSPE ON DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.- <br /> E H 1426 7/72 1M <br />