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SAN JOAQUIN LOCAL HEALTH -DISTRICT <br /> FOR OFFICE USE: 16p1 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �_5 5 Z. <br /> THIS PERMIT EXPIRES 1' YEAR FRONT DATE ISSUED , Date Issued <br /> } (Complete In Triplicate) -� 3 _ L <br /> Application is hereby de 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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 36 OD CENSUS TRACT <br /> r r j <br /> Owner's Name Phone <br /> Address <br /> City <br /> V�' � _. .,._ ... ..._ C`S7 <br /> o Contractor's Name �� License # 2,1V Phone <br /> _361 F-3311-3 <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT .PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> . Industrial I Cable Tool Dia, of Well Excavation ' <br /> Domestic/private I Drilled Dia. of Well Casing z <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation 3 Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grout <br /> 1 Other Other Information ' <br /> PUMP' INSTALLATION: Contr aC for V� Q <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ._ --- <br /> ESTRUCTION OF WELL: Well Diameter - Approximate'Depth°"' <br /> Describe Material and Procedure s <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 s true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY " DATE <br /> ADDITIONAL COMMENTS: ---- <br /> PHASE II GROUT 'INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. # <br /> E H 1426 4/72 1M <br />