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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE US ^ : 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. <br /> THIS 'PERMIT EXPIRES I' YEAR FROM DATE ISSUED Date Issued -`'2) <br /> (Complete In Triplicate) <br /> 'Application is hereby made2t0 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 /> � S <br /> ,TOB ADDRESS/LOCATION l C , CENSUS TRACT <br /> Owner's Name Phone <br /> Address �. <br /> Al 65 city ._611 6_1r; ll <br /> Contractor's Name 1�(. License �� � _ <br /> f l = G' ? Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_� RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK (] SEWER LINES PIT PRIVY <br /> SEWAGE DISPOIELD CESSPOOL/SEEPAGE PIT OTHER { <br /> INTENDED USE TYPE OF WELL NSTRUCTION SPECIFICATIONS s <br /> _ Industrial Cable Tool Dia of 11 Excavation 40 <br /> Domestic/private .Drilled 1 o ell Casing <br /> Domestic/public �I3riiren Casing (�(� <br /> Irrigation - ..Gravel Pack Grout Seal <br /> Other Rotary : pe of Grout g''2x; y;r <br /> Other Information <br /> PUMP INSTALLATION:` Cont ctor <br /> "Type of -P H.P. o <br /> PUMP REPLACEMENT: / / _State Work Done <br /> PUMP REPAIR: / / 'S_tate- Work Done <br /> .7ES_TRUCTION 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 s true to the best of my knowledge and belief. <br /> SIGNED n ,3 <br /> _ TITLE � e <br /> (DRAW PLOT >PLAN ON REVERSE- <br /> SIDE)-FOR DEPARTMENT USE ONLY <br /> PHASE i __- <br /> APPLICATION ACCEPTED BY A DATE <br /> ADDITIONAL COMMENTS: - f <br /> PHASE II GROUT INSPECTION _.,,.PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ' INSPECTIONu'BY DATE" <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />