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SAN JOAQUIN LOCAL HEI ALTN DISTRICT <br /> FOR F ICE USE: 1601 E. Hazel;ton. Ave.", Stockton, Calif. <br /> Telephone: (209),.466-6781 <br /> ' LIZ APPLICATION FOR WELL CONSTRUCTIONA,OR PUMP PERMIT Permit No. <br /> THIS PERMIVEXPIRES, I,YEAR;FROM DATE- ISSUED Date Issued <br /> (Complete In-Triplicate) <br /> Application`7is-hereby-,made.fto the<iSangJoaquin Local: Health Distract for..'a permit- to Construct <br /> and/or install the work herein described. This•.applicationl s made in compliance with San Joaquin <br /> County Ordinance:No:,,,:186 2van&,r.the ,Rules=-and,:Regulations -of:-the . San Joaquin Local Health 'District. � <br /> -vF "fid;?N.? 1+:ti �� t1n'� :!v-_. <br /> .TOB ADDRESS/LOCATION L Q Qw. ;CENSUS TRACT <br /> s3 :S <br /> #' " �e'r. <br /> Owner's :Name <br /> Address , City <br /> Contractor's Name License # Phone ' <br /> t <br /> TYPE OF WORK (Check) : NEW WE'LL 'W DEEPEN/ / RECONDITION /_/ DESTRUCTION /7 <br /> t PUMP INSTALLATION PUMP' REPAIR % PUMP REPLACEMENT /� <br /> r r Other / <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 _ ,9 <br /> Domestic/public Driven Gauge of 'Casing 6' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other . Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Conttactor <br /> (,,.Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> ze <br /> PUMP REPAIR: State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> 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 Sari Joaquin Local Health District a <br /> WELL DRILLERS REPORT of th el and notify them before putting the well in use. The above <br /> information s true to th' s of my knowledge and belief. <br /> SIGNED A TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE T FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: -'— <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /0' 72- <br /> CALL FOR A GROUT_INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H' 1426 r , 4/72 1M <br /> k <br />