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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> VOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Yj� <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 � e/k4,,q /z e,,6 S 4.VA� CENSUS TRACT <br /> • t <br /> Owner's Name j,{/ Phone ' <br /> _ Q r � - -- <br /> Address 2 — City <br /> Contractor's Namea.� License �� � Phone .2 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION-/--7° <br /> PUMP INSTALLATION /�/ PUAH' REPAIR '&7 PUMP REPLACEMENT /- j <br /> Other /µ / <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 i <br /> Irrigation Gravel Pack Depth of Grout Seal o <br /> Other Rotary Type of Grout <br /> Other Other Information { <br /> E <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: AV State Work Done <br /> -PUMP REPAIR: State Work Done <br /> .tr <br /> ESTRUCTION=OF .WELL: - Well Diameter Approximate Depth ...- <br /> Describe Material and P ocedure <br /> IM& Pa XD <br /> I hereby agree to comply with all laws and regulations of the San Joaquin L cal 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 rue to the best my knowledge and belief. - i <br /> SIGNED TITLE <br /> ' PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE v2 <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />