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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L- to <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued - S `1?� <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 in compliance with San Joaquin <br /> County Ordinance No. 1862 and the. Rules:and Regulations of the San Joaquin Local Health District. S <br /> JOB ADDRESS/LOCATION `tL CENSUS TRACT y� <br /> Owner's Name --- _ Phone <br /> - _. — <br /> Address 111 :3 <br /> City <br /> r � _ License <br /> Contractor ��l Q 3Z�' Phone 7 ,/;j 7 <br /> a Name _ t� <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN "/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /7/ PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /fg�> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER O� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ire Tool Dia. of Well Excavation <br /> iestic/private Drilled Dia, of Well Casing _/6 <br /> _ <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 /> ,.r---- - <br /> H.P.Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 /> SIGNEDTITLE W � ��� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �- <br /> APPLICATION ACCEPTED BY DATE ___,r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IU/FINAL INSPECTION <br /> INSPECTION BY DATE 'r/�-'�'Z/ INSPECTION BY DATE -/ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />