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AN JOAQUIN LOCAL HEALTH DISTRICT <br /> P <br /> F'Ok OFFICE USE:" . li 01 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 IssuedG <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 an Regula" ns of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS A CT 1 <br /> Owner's Name Phone <br /> Address .� �. City ' <br /> Contractor's Name License 111774P/&4 Phone g0.33 <br /> TYPE OF WORK (Check_ ): NEW WELL /�% DEEPEN RECONDITION /_� DESTRUCTION /-7 <br /> _ <br /> PUMP INSTALLATION /' PUMP REPAIR /—/ PUMP REPLACEMENT f-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK= SEWER LINES. PIT PRIVY,'--- <br /> SEWAGE <br /> RIVY '--,SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 ;1 <br /> Irrigation Gravel Pack Depth of .Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <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 Distriet 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 /> i <br /> SIGNED TITLE <br /> vf <br /> (D-RAW-PLOT PLAN ON REVERSE S,I. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE G D G <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 3.426 7/72 1M <br />