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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE:,a X601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. (� <br /> d <br /> THIS PERMIT EXPIRES 1 YEAR, FROM DATE 'ISSUED , Date Issued /- 7� 2 <br /> (Complete In Triplicate) <br /> Application is hereby.'made to the San Joaquin Local Health District for a permit to constructs <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 /> JOB ADDRESS/LOCATION � S CENSUS TRACT ' <br /> Owner's Name "���S ''� Phone ' <br /> • F <br /> Address City �p ^_ <br /> Contractor's Name ,S' License # <br /> Phone37 '� <br /> TYPE OF WORK (Cheek) : NEW WELL '/ / DEEPEN '/ / REC6NDITION /_ . DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /Z:7' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 'LINES PIT PRIVY <br /> SEWAGE DISPOSALI IELD CESSPOOL/SEEPAGE PTT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <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.`, .,, 4' ;Depth of Grout Seal . C <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMPINSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAI-R-: /.- / S to to,Work Done-,- -- 1 <br /> .PESTRUCTION_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 /> SIGNEDf, <br /> _ TITLE---. �Z� ,,.,.__„ <br /> L11— <br /> (DRAW PLOT PLAN ON REVERSE SIDE)- <br /> PHASE <br /> IDE)PHASE I <br /> APPLICATION ACCEPTED B 'G DATE 7 y <br /> ADDITIONAL COMMENTS: <br /> PHASE .II GROUT INSPECTION PHASE/III4FINAJL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �r1/ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 <br />