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C' + SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POR OFFICE`USE:. - ' 1601 -E. Hazelton Ave. ,,Stockton, Calif- <br /> _. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> F <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 Saiz Joaquin. <br /> County Ordinance No. 1852r ul,ed �e ulationsl f the San Joaquin Local Health District. + <br /> JOB ADDRESS/LOCATION �� ' -�a��, e.�. CENSUS TRACT <br /> Owner's Nage Phone <br /> Address _ City a-Lk, <br /> Contractor's Name ,��� License M y J Phone /6 d <br /> _ DEEPERECONDITION /_� DESTRUCTION x <br /> TYPE OF WORK (Check) : NEW WELL /� /_7 <br /> N_ N_ _ <br /> PUMP INSTALLATION. / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .PIT OTHER 'J <br /> E �� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia, of Well Excavation /a <br /> omestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing - <br /> 1,1Irrigation Gravel Pack Depth of Grout Seal . U ' <br /> Other Rotary Type of Grout q <br /> -- - Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ,, _ _ H.P. z- <br /> PUMP REPLACEMENT: / ./ State Work Done <br /> PUMP REPAIR: / /. State Work Done - - � <br />„RESTRUCTION 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 Heajth 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 /> 49 <br /> SIGNED ' / � _ _ TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I � € <br /> APPLICATION ACCEPTED BY DATE 7� <br /> ADDITIONAL COMMENTS: f <br /> PRASE II GROUT INSPECTION ;- PHASE III/FINAL INSPECTION i <br /> INSPECTION BY DATE' .. Z& INSPE6TION BY DATE` <br /> CALL FOR A GROUT^INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4• E H 1426 7/72 1M <br />