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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2__2j1/0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued !��_�, <br /> (Complete In Triplicate) <br /> Application -is..hereby.made- to the. San Joaquin Local Heal.th 'District for .a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquit <br /> County Ordinance No. , 1862 and the-Ruleswand Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� �qQ, CENSUS TRACT 1j Y <br /> Owner's Name ;(�� Phone <br /> Address City <br /> " Contractor's Name r License # 17-476 0 Phone 2 - J' <br /> TYPE OF..WORK. (Check): NEW_WELL '/ / DEEPEN RECONDITION RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION � PUMP REPAIR / / PUMP REPLACEMENT <br /> 0 her <br /> I <br /> DISTANCE TO NEAREST: 9EVIC TANK - SEWLR L ES 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 w Gravel Pack `�Dep-thxof Grout-Seal---------- <br /> Other Rotary Type of Grout <br /> Other. Other Information <br /> k PUMP INSTALLATION: Contractor <br /> Type of Pump a H.P. <br /> p1 <br /> p <br /> � PUMP REPLACEMENT: X State Work Done / <br /> PUMP REPAIR: XT -State Work Done <br /> ,DESTRUCTION OF WELL: e� Dia ter 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 i true to' th best of my knowledge and belief. <br /> SIGNS TITLE �� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE,— INSPECTION BY 4111DATE A 2. �d <br /> CALL FOR A.GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 w LL f 4/72 1M <br />