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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1641 E. Hazelton Ave. ,- Stockton, Calif. <br /> Telephone: (204) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 . d <br /> THIS PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED Date Issued bC-1TIz,' <br /> (Complete In Triplicate) <br /> Application is hereb 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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONr� �•� •� �"-^ CENSUS.TRACT' <br /> Phone` �a <br /> Owner's Name <br /> Address . �t � .�c.�n QJ City <br /> License # �j 73 Phone <br /> Contractor's Name 6 <br /> 1 TYPE OF WORK (Check) : NEW WELL / I DEEPEN RECONDITION /7 DESTRUCTION IT <br /> PUMP INSTALLATION I I PUMP REPAIR /XI PUMP REPLACEMENT l^T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK A SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD r CESSPOOL/SEEPAGE PIT OTHER <br /> # INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> I Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> i Irrigation Gravel Pack Depth of Grout Seal <br /> -- Other Rotary Type of Grout <br /> Other Other Information _ <br /> E <br /> PUMP INSTALLATIONS { Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> L- PUMP REPAIR: /Y:/ State Work Done avu <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 /> i and the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> I will furnish the San Joaquin Local Health District a <br /> after completion of my work on a new well, <br /> f 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 /> TITLE <br /> SIGNER r . <br /> (DRAW PLO LAN REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY AV DATE <br /> CALL FOR & GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ON. 7/72 IM <br /> E H 1426 <br />