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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FM OFFICE USE: / 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 1 YEAR FROM DATE ISSUED Date Issued, 7- 7-7Z i <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 is b -.aLd the Fule and egulations of the San Joaquin Local Health District. <br /> j . <br /> JOB ADDRESS/LO „ONCENSUS TRACT <br /> Owner's Name Phone <br /> AddressCity <br /> Contractor t s Name License #�00 J r'r'Q Phon &-2 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INS TION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> c� <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 Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> a <br /> PUMP INSTALLATION. Contractor ' <br /> Type of Pumf `"` ' H.P. <br /> PUMP REPLACEMENT: / f State Work 4ne <br /> PUMP. REPAIR. .- -- / / 7S.tate Work Donee <br /> ,DESTRUCTI.O_N_ 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 /> SIGNED /,% ', TITLE /9�,44 <br /> (DRAW-PLOT PLAN ON REVERSE S14 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7-7-Zl' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P III F NAL INSPECTION <br /> INSPECTION BY BATE INSPECTION BY/.,,,) DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />