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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ! <br /> Telephone: (209) 466-6781 � i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7zL <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is ereby 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 A <br /> CENSUS TRACT ' S <br /> Owner's Name Phone_ _- .__ � <br /> Address City <br /> Contractor's Name. License cif Phone <br /> --. - <br /> TYPE OF WORK (Check) : NEW WELL -/ / DEEPEN /. / RECONDITION /_/ DESTRUCTION — <br /> PUMP INSTALLATION / I PUMP REPAIR/' PUMP-REPLACEMENT /�j <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES : PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE STYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />` Industrial Cable Tool Dia. of Well Excavation �► <br /> Domestic/private } Drilled Dia, of Well Casing <br /> 1 Domestic/public Driven Gauge of Casing <br /> k Irrigation -Gravel Pack Depth of Grout Seal <br /> i Other ' Rotary Type of Grout <br /> Other <br /> t Information Other In r�ua on Y ..-----;•H- <br /> PUMP INSTALLATION: Contractor ,. <br />` Type of Pump H.F. <br /> 74 <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> f - � <br /> PUMP_ REPAIR: State Work Done-' <br /> ,DESTRUCTION OF WELL: Well Diameter f , Approximate Depth <br /> Describe Material and Procedure <br /> 4 <br /> f <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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATED ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 11_I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY~ Z!�/_ DATE F-,r7 <br /> , CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. fff <br /> E H 1426 - 4/72 1M <br />