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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> J 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -_ I Telephone: (209) 466-6781 <br /> _ Z APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permi;. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date <br /> (Complete In Triplicate) <br /> >Cpl ic..ti 00 is her&y haje to the San Joaquin Local Health District for a permit to conn , w <br /> an /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 ]its+Kh District. <br /> .TOE ADDRESS/LOCATION _ ��� A CENSUS TRACT <br /> Owner's Name �(� i' , � � Phone <br /> Address � ¢ <br /> City c Well 1 ' <br /> Contractor's N. re License `> Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> i UUP INSTALLATION PIMP REPAIR / / UMP REPLACEMENT /__7 <br /> _/ <br /> :.her — \ <br /> DIS'IAiV"C L 'I0 NEAREST: SEPTIC i,.: ::, e _4_ SEWER LINES PITT' PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> N`''E''kDRD FTSE !TYPE OF WELL CONST UCTION SPECIFICATIONS <br /> Industrid._iCable Tool Dia. of Well Excavation �e <br /> Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public —y� Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal t <br /> Other _ Rotary Type of Grout <br /> Other Other Information ,-. <br /> r <br /> INSTALLATION. Contractor X <br /> ! <br /> e. <br /> Type of Pump .�e, H.P. <br /> �. <br /> / / State Work Done <br /> 2U iP 't_EPAIR: / / State Work Done <br /> FATRUCTION OF- v1ULL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> .7 hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> "ad the Stare of Caiifornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> a ger completion of my work on a now well, I will furnish the San Joaquin Local Health District a <br /> `.;L!L DRi LERS REPORT of the well and notify them before putting the well 'n use. The above <br /> is oA❑aL oa is true to the- best of my knowledge and belief. <br /> SIGNED <br /> TLTLE <br /> — (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> i'.'. iC 'TION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PEASE II GROUT 1NSPEC`i0N PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE AJ-4-- , INSPECTION nY <br /> - DATE <br /> CALL 'rOR A GROUT INSPECTION PiZ.i61 TO GROUTING AND FINAL INSPECTION. <br /> E A 1423 5/73im <br />