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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ;' 1601 E. Hazelton Ave. , Stockton, Calif. W <br /> Telephone: (209) 466-6781 76 - 3s-6 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued b <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 CENSUS TRACT <br /> Owner's Name �' ti Phone ��(�� <br /> Address `? ��, l �+C City <br /> Contractor's Name / ��� License #� Phone <br /> TYPE OF WORK (Check): NEW WELL , DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION 0 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 <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1Z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout _ <br /> -- \ <br /> Other Other Information � \" <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Z <br /> PUMP REPLACEMENT: / 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 REPORthe well and notify them before putting the well in use. The above <br /> informati .is.-. a st o y knowledge and belief. <br /> SIGNED -f �'�'G'� -_ TITLE 'y��2 � <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I Vf <br /> APPLICATION ACCEPTED B ✓ DATE Z <br /> ADDITIONAL COMMENT <br /> PI INSPECTION PHA N INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE =2 3- <br /> CALL FOR A , SPECTION PRIOR TO GROUTING AND FINAL INS <br /> PE ' <br /> E H 1426 .f' �' 7/72 1M <br />