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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. 2� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z4.Zy,7j <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 .SUS TRACT <br /> Owner's Name Phone J c �� <br /> Address 3 -�-/ City <br /> Contractor's Name 0 License #I G -137.3 Phone3L 0 13 <br /> TYPE OF WORK (Check): NEW WELL6C7DEEPEN /-7 RECONDITION /_-7 DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION ,'_PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK p( SEWER LINES /00 1 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation ol '� <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /p <br /> Irrigation Gravel Pack Depth of Grout Seal SO <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. S " <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: L/ 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 /''CSA ,._. TITLE <br /> ILI (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY _.." <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAs& iQjWWtcT0 PHASE; III FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY DATE 2., <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />