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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. T <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date IssuedJ?� <br /> d (Complete In Triplicate) <br /> Application is hereby made -to 'the San Joaquin Local Health District for a permit to1 .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 /> r JOB ADDRESS/LOCATION ; <br /> y CENSUS TRACT <br /> Owner's Name Phone <br /> Address zkJr <br /> City Cs <br /> Contractor's Name , �_� �} �w License # Phone S" <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR R! PUMP REPLACEMENT /? <br /> Other <br />{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED­USEkA <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS lr' <br /> Industrial , Cable Tool Dia. of Well Excavation } <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 4) ' <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 <br /> H.P. <br /> f _ <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR"° S toe"go <br /> ALI <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the ;an 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 , s� �r� ► _ TITLE <br /> (DI ,W PLOT PLAN O_N REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED n <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS FINAL INSPECTION <br /> INSPECTION BY DATE _ _ INSPECTION BYDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO.GROUTING AND ,FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />