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Le' 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. Z3 �4 ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //6-/7,3(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 Joquin <br /> County Ordinance No. 1862 and the Rules aa <br /> and Regulations of the San Joaquin Local Health District-. <br /> JOB ADDRESS/LOCATION J CENSUS TRACT <br /> Owner`s Name 'S Phone } <br /> Address' <br /> �n <br /> City <br /> Contractor'e <br /> Name � ,y ,;� � _ License Phone g� <br /> TYPE OF WORK (Check) : NEW -WELL; / /. DEEPEN'/_/ RECONDITION /_7 DESTRUCTION /- <br /> PUMP­INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other. ./7/-. <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 /> k Domestic/private Drilled Dia. of Well Casing y' <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 <br />� PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ `H.P. �. <br /> PUMP REPLACEMENT: / / State Work Done . <br />"PUMP REPAIRo _ -,o�.��/ , tat"e'Work"Don`e '� <br />', ,,RES_T_RU_CTION 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 anew 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 be to my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />' PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION P IJX AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROU INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />