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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160 : E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PU;�P PERMIT Permit No. � <br /> THIS PERMIT..MIRES 1 YEAR FROM DATE ISSUED : Date Issued J-1Z,7 Z <br /> (Complete In Triplicate) <br /> Application is hereby _de 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 and Regulations of the San Joaquin Local Health District. <br /> u� �y <br /> JOB ADDRESS/LOCATION �7 CENSUS TRACT <br /> Owner's Name f Phone <br /> Address ;7,� Cityc- L <br /> I <br /> Contractor's Name F' /l License 44MM � <br /> Phone <br /> TYPE OF WORK (Check) . :NEW WELL /DEEPEN -/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION —PUMP REPAIR '/ / PUMP REPLACEMENT /-7 <br /> i Other ! / <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES _ PIT PRIVY <br /> -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE .—_ TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> � dusCrial Cable Tool Dia. of Well Excavation <br /> zl�Dome Drilled Dia. of Well Casing -Z" <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 /> PUMP INSTALLATION: : .Contractor <br /> , .Type of Pump H.P. <br /> PUMP REPLACEMENT: i / / State Work Done <br /> I <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 myk.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 f TITLE f <br /> i <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE oor <br /> ADDITIONAL COMMENTS: <br /> PHASE IIiGROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYD TE -2 Z INSPECTION BY DAT <br /> CALL FOR A GROUT IA3S ECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 I; 4/72 IM <br />