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l// SAN JOAQUIN LOCAL HEALTH DISTRICT s <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif, I <br /> Telephone : (209) 466-6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT -Permit No, Jam- 4.3 eel w <br /> THIS PERMIT' EXPIRES I YEAR FROM DATE ISSUED -Date,Issued <br /> : .(Complete In Triplicate) <br /> Application is hereby'mademto ,the`San Joaquin Local Health District for a ,pers'nit 'to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 862 a d the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION, nCENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> _ <br /> �sCity <br /> red <br /> Contract, ' Name Oil ' T - - <br /> License #/dam Phone? <br /> rj 4 <br /> TYPE .OF WORK (Check): NEW WELL DEEPEN /_ RECONDITION DESTRUCTION if <br /> PUMP INSTALLATION J / PUMP REPAIR / / PtrMP REPLACEMENT /_7 S <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK k 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 S •r <br /> Domestic/private - Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth' of Grout Seal Q <br /> Other I,- Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR- / J State Work Done <br /> ESTRUCTION OF WELL: Well Diameter j- Approximate Depth <br /> Describe Material and Procedure <br /> i <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 It <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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ._ <br /> PHASE II GROUT INSPECTION. PHASE III FINAL INSPECTION <br /> INSPECTION BY ATE IN5PEC ON BY DAT <br /> CALL FOR A GROUT -INSPEC ION_PRIO _TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />