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� ' • SAN JOAQUIN-LOCAL-`• HEALTH DISTRICT 44 �{ <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.-, Stockton, Calif. <br /> Telephone: (2091) 466-6781 77 -3I 3 Vj <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. - (� <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 t ules and Regulations of the San Joaquin Local Health District. <br /> JOBIRDBRMAOCAzz <br /> TIONV CENSUS TRACT <br /> Owner's Name' ; } a Phone' <br /> Address , Citly�, _ <br /> Contractor's Name License,OX. Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION.'/_ <br /> PUMP INST LATION / J PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other /_7 <br /> DISTANCE -TO NEAREST: SEPTIC TANK SEWER LINES _ —Q -PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CL'sSP6®LaSEEPAGE PIT OTHER <br /> INTENDED USE TYPE ~OF 'WELL - CONSTRUCTION SPECIFICATIONS v <br /> Industrial <br /> aprivate Cable Tool 5 Dia; of Well Excavation <br /> Domestv <br /> Drilled. ,.. Diaj. of Well Casing <br /> Domestic/public `" 'y9 Driven Gauge of Casing ! <br /> Irrigation ' Gravel Pack Depthxof Grout Seal <br /> Other ------Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumpr H.P. _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> ' (DRAW PLOT PIAN ON 'REVERSE SIDE <br /> �. FOR 4DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAn II / NAL INSPECTION <br /> INSPECTION BY DATE 1 'zj INSPECTION BY ,DATE <br /> CALL FOR A GRO�T��IN5PECTION PRIOR TO GROUTING. AND FINAL INSPECTION. <br /> E H 1426 " '7/72 1M <br />