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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR CfVFI9E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATLO 'ISSUED Date Issued. _-lel_-? <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 yin compliance with San Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOC ON A jpP !m t le wo a-44:, lb-p t-j _ CENSUS TRACT <br /> Owner's Name Q Phone / <br /> Address �' ! �sC - City . csyi0 Z <br /> Contractor's Name License # _ hone z <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_ <br /> { Other / ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERI =. <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 /> CL Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout w <br /> Other Other Information <br /> PUMP INSTALLATION: r. Contractdr <br /> Type of Pump ..Z-,/ .4? H.P. <br /> p <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter F ; Approximate Depth <br /> } Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin'Loca1 Health District <br /> and the State ,of California pertaining to o_r _regulating well construction.. Within FIFTEEN DAYS <br /> f after completion of my work on a he'w"well, I will furnish the San Joaquin• Local Health District a <br /> WELL DRILLERS REPORT of the well and notify thein before putting the wall in use. The above <br /> information is true to the best of y know edg and belief. <br /> SIGNS _ Aftxz�za ITLE <br /> DRAW LOT PLAN 0 VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS IJIFINjAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING.AND FINAL INSPECTIQ1r. - <br /> E H 1426 7/72 1M <br />