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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOi;� OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-678114) <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. (o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 ,4goaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health D m'putp. <br /> JOB ADDRESS/LOCATION fGai�//���r�rct CENSUS TRACT <br /> Owner's Name S, C C c� r ri ¢ r Phone <br /> Address A City <br /> Contractor's Name License # ),j 1hone z <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /&W 7PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other L/ <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 /> J <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 jr <br /> PUMP INSTALLATION Contractor tl.cc <br /> Type of Pump AV H.P. <br /> PUMP . j_/ State Work Done � ,/� <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 �s1' <br /> RA P PLAN N ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL' INSPECTIO <br /> E H 1426 7/72 1M <br />