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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. -ay <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5,-j4 <br /> - 3 <br /> (Complete In Triplicate) <br /> Application is hereby made 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 /> JOB ADDRESS/LOCATION C��/� /� 0,,.w CENSUS TRACT <br /> Owner's NamePhone <br /> Address ��/ (e City 110F�o <br /> Contractor's Name ,� License #/Ji phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION /7/ PUMP REPAIR / / P REPLACEMENT /-7 <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 <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 i <br /> Other Rotary Type of Grout 4r <br /> Other Other Information <br /> folop <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP State Work Done <br /> .�— — <br /> PUMP REPAIR: State Work Done <br />,DESTRUCTION OF WE 7, Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to com*ly with all laws and regulations of the San Joaquin Local Health District <br /> and the State of C4Varnia 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 nd ief. <br /> SIGN D '.; CAS' TLE <br /> (DRAW PLTV PLAIT0 REV SE 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 INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />