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O� ySAN 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. 7S- <br /> THIS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z -3-Z3 <br /> (Complete In Triplicate) 2-0 - Ilo--t S' <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 /> JOB ADDRESS/LOCATION /toaa .,' --` CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name r - License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATIONPUMP REPAIR/ / PUMP REP CE NT 17 <br /> Other / / ( �- <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' {� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .� H.P. ^/O Q- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done r T <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 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 /> SIGNED 6 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR D TMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCE BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE/49 -= -�7 - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IM <br />