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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE:E 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION;OR PUMP PERMIT Permit No. 7� /O <br /> THIS PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED Date Issued ,/ _7 <br /> (Complete Iri'Triplicate) 'it to <br /> a perm <br /> Application is hereby made to the-San JJoaquin��oact <br /> pplicationHealth Diatmade iririct rcompliance withnSanuJaaquin, <br /> and/or install the work herein dere <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i CENSUS TRACT <br /> JOB ADDRESS/LOCATION IfO <br /> . Phone ` <br /> Owner's Name � <br /> City <br /> Address . <br /> License # Phone <br /> Contractor's Name <br /> QTY-PEYOF WORK—(Check) : NEW WELL DEEPEN RECONDITION /_� DESTRUCTION /_ T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> k Other <br /> I' <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 p <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public <br /> Driven Gauge of Casing <br /> k . Irrigation Gravel Pack Depth ,of Grout Seal <br /> CIO <br /> Rotary Type of Grout <br /> t Other y <br /> Other Other Information <br /> T <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> f L <br /> PUMP REPAIR: / / State Work Donet- <br /> _.._ APPr ximate Depth <br /> ; DESTRUCTION OF WELL: ' Well Diameter <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 and notifyew well, Ithemwill <br /> beforefurnish <br /> puttingSan <br /> theowellninouse.cal HeThehaboverict a <br /> WELL DRILLERS REPORT of the well <br /> information is true to the best of my knowledge and belief. <br /> TITLE <br /> SIGNED <br /> (DRA PLOT PLAN -ON REVERSE SIDE - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE// ,4—7a-- <br /> INSPECTION BY DATE 4 <br /> + CALL FOR A.GROUT INSPECTION PRIOR -TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> E H 1426 <br />