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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. ��.571a}� <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-3o-76 <br /> (Complete In Triplicate) <br /> I 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and gulati ns of the San Joaquin Local Health District. <br /> JOB ADDRESS/PW4TION CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address �l _ <br /> City <br /> Contractor's Name License # Phone a <br /> i <br /> i TYPE OF WORK (Check): NEW WELL / J DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other V/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPM -FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f Industrial Cable Tool Dia, of Well Excavation V <br /> i <br /> :;XDomestic/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 k <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> 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 . -mss _ TITLE <br /> J�jr/ - F'` (DRAW PLOT PLAN ON REVERSE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE3 J17, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHXSEj INSP ION <br /> ; INSPECTION BY DATE INSPECTION BY 2 DATE <br /> ' CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> F- <br />