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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1501 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: - (209) 456--6781 S� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S-�3 <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. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> r Phone <br /> Owner's Name � iiIYYL-� <br /> City <br /> Address �°7 <br /> Contractor's Name License #= YPOne <br /> W:Z� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN I I RECONDITION /� DESTRUCTION /rT <br /> PUMP INSTALLATION PUMP REPAIR. / / 'PUAP REPLACEMENT /� <br /> Other / / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC IL4� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> LINECESSPOOL/SEEPAGE PIT OTHER <br /> i � I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ." <br /> kCable Tool Dia. of well Excavation <br /> I <br /> ndustrial <br /> i Domestic/private Drilled Dia. of Well CasingLA <br /> Domestic/public Driven Gauge of Casing - <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout , <br /> C OtherOther Information <br /> f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> r <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Appr ximate 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 /> r 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 /> TITLE <br /> SIGNED <br /> (DRAWTPLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTEDBY <br /> ADDITIONAL COMMENTS: PHASE II./FINAL INSPECTION <br /> PHASE II G T N EG N INSPECTION BY f ,DATE 0 "2 G <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 .IM <br /> 4 E H 1426 <br />