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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> " APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED. ', D"ate Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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/LOCATIO ' <br /> CENSUS TRACT y <br /> Owner's Name Phone _ -22 <br /> Address , City <br /> y 4 • -may <br /> Contractor's Name ef License icyPhone <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /_/ RECONDITION /7 DESTRUCTION /`7 <br /> PUMP INST TION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/`�``� CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF ELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial CableTool Dia. of Well Excavation ' <br /> \.I�omestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ' <br /> r Gravel Pack Depth of Grout Seal r <br /> Other Rotary Type of Grout. , <br /> Other Other Informtion <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / 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,] 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 rue to the bes of my knowledge and belief. <br /> SIGNEDA) - TITLE <br /> (D PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE -2 -j--2,3 <br /> ADDITIONAL COMMENTS: �-- <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _efL;P DATE ,L-4C-Z,2 INSPECTION BY DATE _e-_73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �� <br /> E H 1426 7/72 1M <br />