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\, 44 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 13 - 537 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3 <br /> -7 ? �'►�`� -� . (Complete In Triplicate) ,_ r ^ CFO <br /> Application is hereby made to the San Joaquin Local Health District gor 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 /> JOB ADDRESS/LOCATION <br /> . " SUS TRACT <br /> Owner's Name Phone d� <br /> Address City <br /> Contractor's Name y ! License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> AL <br /> PUMP INSTLATION � PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK NEWER LINES PIT PRIVY <br /> 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 <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 /> �G <br /> PUMP REPLACEMENT: / / Stato Work Done <br /> PUMP REPAIR: / / State Work Done �t <br /> .RESTRUCTION OF WELL: Well Diameter Approximate Depth Q <br /> Describe Material and Procedure J <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 he best of my knowledge and belief. <br /> SIGNED TITL <br /> DRAW PLOT PLAN ON REVERSE S DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 'F— --2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IJ44FJNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />