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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORtOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -�Z <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 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 Phone <br /> Address _ S ft e-0 s �&0 City <br /> Contractor's Name �,,r-ee A0 License # Phone <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN -7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER L4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 6 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public _ Driven Gauge of Casing 3y <br /> Irrigation _ Graviel- Pack Depth of Grout Seal s <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor +/Y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter (0 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 ���e� Q�� rf" ��/y��� TITLE <br /> C(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE '�i 3 <br /> ADDITIONAL COMMENTS: . p 4,9 W10:2 p <br /> PHASE II GROUT INSPECTION r S III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION' .RIOR TO GROUTING AND FINAL INSPECT <br /> E H 1426 ' 7/72 1M <br />