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C� ` SAN JOAQUIN LOCAL HEALTH DISTRICT win <br /> FOR OFFICE USEV 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) ,4664-6781 <br /> APPLICATION FOR WELL CONSTRUCTION=`OR PUMP PERMIT Permit No. <br /> / THIS PERMIT EXPIRES 1 YEAR "FROM ➢ATE =ISSUED ` DateIssued 7 <br /> (Complete InTripl�ica"te} .,., <br /> Applicata;,oni,i$Dhereby-,-madexlto bhei--,$an Joaquin Local Health District for a,permit to construct <br /> and/or install the work herein described. This applicationFis,made in compliance with San Joaquin <br /> County ,Qrdinaneef,,No-. ;1862i�-and°;.-thec,Rules'.aa and Regulations of,the San Joaquin:Local: Health District. <br /> JOB ADDRESS/LOCATION ,�(� j .,CENSUS TRACT <br /> d <br /> y <br /> Owner s,;Name :1 4A s'' ii-1 - Phone <br /> Address @ <br /> City <br /> Contractor's Name License # 1 Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /-7 DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> Industrial Cable Tool Dia. of Well Excavation "V <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Q <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: / / State Work Done <br /> PUMP REPAIR: / / State Work Done 6 "t(., l .4 4 , <br /> t 1. <br /> ,DESTRUCTION OF WELL: Well Diameter +3yr ~ � 4Approximate 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 TITLE <br /> -�- <br /> (DRAW PLOT PLAN N REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY C, 13 DATE 2d 9? <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> EH1426 _ <br /> 4/72 1.M <br />