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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: V��1601 E. Hazelton Ave. , -'Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION'OR PUMP PERMIT Permit No.T.S_ALI&J <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued4-,2;3 <br /> - (Complete In Triplicate) <br /> a Application is hereby made to the' San Joaquiri 'Local Health District -fora permit to construct <br /> and/or install the work herein described. This application i's made in compliance with San Joaquin <br /> County Ordinance Na. 1862 and the Rules and Regulations of the San Joaquin Local .Health District. <br /> JOB ADDRESS/LOCATION ` 0�/4{s` C�C�® CENSUS .TRACT <br /> Owner's Name r. �. _ Phone <br /> Address AJA City . <br /> Contractor's Name JLicense Phon <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION 1-7PUMP INS LATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <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 <br /> Industrial Lble Tool Dia, of Well Excavation Of <br /> :: Gmmestic%private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 10 4 L_ <br /> irrigation Gravel Pack Depth of Grout Seal <br /> _ Other Rotary Type of Grout 01 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> s _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 thein before putting the well in use. The above <br /> information i true to the bes of my knowledge and.belief. <br /> SIGNED TITLE <br /> WRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I p <br /> APPLICATION ACCEPTED BY '.�. DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR .T.O .GROUTING AND FINAL INSPECTION. <br /> -. <br /> E H 1_426 7/72 1M <br />