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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.� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONS37 bauh CENSUS TRACT <br /> Owner's Name 4a.2 J, Phone <br /> Address City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL' /—T DEEPEN /_% RECONDITIO /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT 1—T <br /> Other 4 / <br /> f <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 i Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type oa f Pump H.P. ! <br /> PUMP REPLACEMENT: / / State Work Done <br />;- PUMP REPAIR: L.4,,�State Work Done <br /> ESTRUCTION OF WELL: -*Vk 1 Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall 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 '. t TITLE <br /> (DRAW PLOT 151,AN OV REVERSE SIDE) / € <br /> FOR„REPARTMENT USE ONLY <br />' PHASE I <br /> APPLICATION ACCEPTED BY D <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION PHAS F 1INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT3NSPEG.T fPRiOR TO GROUTING AND FINAL INSPE T <br /> E H 1426- �,� 7/72 1M <br />