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22z- <br /> 6 SAN JOAQUIN LQC-�L-HEALTH DISTRICT <br /> FOR OFFICE USE: 1601E. Hazelt o"n Ave- , Calif.. Stockton, Cali <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-f� 2 <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 Joaquin1 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J)if e�j �� CENSUS TRACT <br /> Owner's Name Phone <br /> Address City1 <br /> Contractor's Name License # Phone <br /> /A <br /> TYPE OF WORK (Check): NEW WELL _ DEEPEN /_% RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /% T t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —' - _7 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Cable Tool Dia. of Well Excavation 10 <br /> Domestic/private Drilled Dia.;-of well Casing `� <br /> Domestic/public Driven Gauge- of Casing 4 <br /> Irrigation Gravel Pack Depih~of Grout Seal �J N <br /> Other Rotary Type 'of Grout <br /> Other Other .Information - YOF <br /> PUMP INSTALLATION: Contractor {� U <br /> Type of Pump -Vta H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: J / State Work Done <br /> ,DESTRUCTION 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 is4true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> AL (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY�- X11 _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY e., ,. DATE / /`'3 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />