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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. Z—T,�- 17 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7- ' <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 an Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION U RC1 CENSUS TRACT <br /> Owner's NameZe � � Phone `j -� <br /> Address d �C U � =�� <br /> _ City �%6 <br /> Contractor's Name �-/6 <br /> License # % Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /-' <br /> PUMP INSTALLATION /W"^PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> 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 <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial W , Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 `Xrl�) <br /> Type of Pump _ � ;� _ H.P. ' *� <br /> PUMP REPLACEMENT: /7State Work DonefE/// <br /> PUMP REPAIR: <br /> / / State Work Done <br />.PES_TRUCTION 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 /> 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,C TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDI: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT NSPECTION. PRIOR TO GROUTING AND FINAL INSPEC <br /> r E H 1426 7/72 1M <br />