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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> jW Telephone: (209) 466-6781 <br /> APPLICAT ION. FOR _WELL.. CONSTRUCTION OR PUMP PERMIT Permit No. 1,3 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7 <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 San Joaquin <br /> County Ordinance No. -1862. and..the' Rules nd Regulations of the San Joaquin Local. Health District. <br /> ��' :5 <br /> 30B ADDRESS/LOCATION G ACENSUS TRACT <br /> Owner's Name , ' Phone <br /> Address City <br /> Contractor's. Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /7 RECONDITION /_7 DESTRUCTION / J <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other /_7 <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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal m <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: v- <br /> / / State Work Done <br /> f J� <br /> ESTRUCTIQN 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 be of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Mjl& DATE ;,?32- 7..� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M "',1J <br />