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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 l7 �.gi. A) <br />! APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES ,-1 YEAR FROM DATE ISSUED Date Issued 3 <br /> ` (Complete In Triplicate) <br /> t Application is hereby made to the San Jbag6in Local Health District for a permit to construct <br /> and/or install the work herein described. 'Thi-s 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 '. CENSUS TRACT 6 <br /> Owner's NameIUC413�d 7 <br /> Phone <br /> Address J <br /> City <br /> Contractor's Name License !E <br /> a / Phone <br /> TYPE OF WORK (Check) : NEW WELL-4 r DEEPEN /7 RECONDITION /_ DESTRUCTION /_7 <br /> P[1MP INSTALLATON PU1�+IP REPAIR % / PUMP <br /> Other ./ REPLACEMENT /� <br /> % <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> rV� 5 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialable Tool Dia, of Well Excavation <br /> �G Domestic/private j Drilled Dia.- of Well Casing <br /> Domestic/public i Driven Gauge of Casing ` <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> Other Other information! <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. F <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> ESTRUCTION 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 Lat4lTITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY - " <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _ _/�- 7.3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY efjZ DATE :2=f INSPECTION BYDATE !V,10 -77 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.' <br /> E H 1426 7/72 1M it� i <br />