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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 .E. Hazelton Ave. , Stockton, Calif. <br /> E Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,9 S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued, -may-�� <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 Joaquir <br /> County Ordinance No: 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> 2'�I.'1 .0 ,,Gu - ., <br /> ' JOB ADDRESS/LOCATION ,� � ?�/V f1 CENSUS TRACT <br /> Owner's Name <br /> Phone,3�e' / <br /> Address 01 ., City <br /> Contractor's Name /�/ _ License Q / Phone s <br /> G- 61 <br /> TYPE OF WORK (Check): NEW WELL,4;_- �DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> F Other <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1" <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER `�Ip <br /> INTENDED USE TYPE OF WELL ~ <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _0 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge .of Casing <br /> __�Othegation Gravel Pack l Depth -of- Grout Seal <br /> Rotary -Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ✓f` <br /> PUMP REPLACEMENT: / / State Work bone <br /> PUMP REPAIR: / / State Work Done <br /> ,ESTRUCTION 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 a new well, I will furnish the San Joaquin Local Health District a <br /> f WELL DRILLERS REPORT of the•Twe1I and-notify-them before-putting the'we1l�-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 /> PHASE I <br /> FOR DEPARTMENT USE ONLY i <br /> � 1 <br /> APPLICATION ACCEPTED ,BY � DATE �fi <br /> ADDITIONAL COMMENTS' /a i� 7 1� ,yy� � <br /> PHASE II GROUT INSPECTION o� PHASE III/ INAL IINNNS ECT ON ' <br /> INSPECTION BYTE INSPECTION BY DATE J <br /> CALL FOR A GROUT INSPECTION .PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72. 1M <br />