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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> k Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is, hereby made tot he 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 and Regulations of the San Joaquin Local Health District.. <br /> . ! <br /> JOB ADDRESS/LOCATION /— CENSUS TRACT z <br /> Owner's Name Phone7, <br /> Address y¢ty�,E. City <br /> a <br /> Contractor's Nam ,�' /.� /L / License ZZ Phone%&,oP= <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /_� RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTAL TION / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE'TO .NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY A r <br /> a ' ¢{ SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA IONS <br /> Industrial l X, Cable Tool Dia. of Well Excavation ~ <br /> Domestic/privateer it' Drilled Dia. of Well Casing <br /> Domestic/public ­. ij Driven Gauge of Casing A <br /> Irrigation -t --.Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout ---------� <br /> ( Other! ; Other Information <br /> PUMP INSTALLATION: Contractor <br /> M Type of Pump 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',tb the best of my knowledge and belief. <br /> SIGNED TITLE ^-`-- <br /> ` t (DRAW PLOT PLAN ON AVERSE SIDE <br /> FOR DEPARTMENI USE ONLY <br /> PHASE I, - <br /> APPLICATION ACCEPTED..BY _ DATE s2- <br /> ADDITIONAL COMMENTS: <br /> PHASE -II GROUT INSPECTION -- PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE7J <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />