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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 /> PLICATION FOR WELL CONSTRUCTION' OR PUMP PERMIT Permit No. 7 Z =7 6Z- <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <br /> `(Complete. In Triplicate) POLS C4'0-0-6 <br /> Application.,is�.hereby,.made-.-to :.the,San-Joaquin L`oca-I Health District for a permit ,to construct <br /> a and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance`No:il 862. .and'.the,Rules. and- Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION V ' CENSUS' TRACT' <br /> Owner's Natrie ~ Phone' , <br /> . . <br /> qmm <br /> ' Address S ' <br /> City . <br /> a 7._ . , <br /> Contractor's Name -k License #lis Phone_''7 <br /> k ' <br /> -- DEEPENm/�/ RECONDITION /�/ DESTRUCTION /TT <br /> TYPE OF WORK (Check) : NEW WELL _ <br /> PUMP INSTLATION/ / PUMP REPAIR -/ / PUMP REPLACEMENT /� <br /> AL <br /> Other: / / <br /> DISTANCE TO NEAREST: SEPTIC TAN EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ) TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ` _/ able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 14 _ <br /> Domestic/public Driven Gauge of Casing l i <br /> irrigation Gravel Pack Depth of Grout Seal <br /> { Other Rotary Type of Grout l f <br /> Other Other Information r <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 /> Y 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 /> k 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 t1 TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY A 'E '"" 72. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 4/72 1M <br />