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ale ^ 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. 212—,,,,eV1 <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - f'Date' Issued <br /> (Complete In Triplicate) a ` <br /> Application is hereby made to- the San 'Joaquin Local Health District for a `,�ermit .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 Rifles and ul.ations of the Joaquin Local Health District. # <br /> JOB ADDRESS/LOCATION f S�i �/� CENSUS TRACT . <br /> Owner's Name . _�_.' ..._f / Phone " [ <br /> Address r. _ _ �/� City <br /> Contractor's Name �f'� "� License # Phone / <br /> Gav G0J <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLA ION / / P REPAIR / / PUMP REPLACEMENT /_ r <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 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 <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: / / 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, 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 best of .my knowledge and belief. <br /> SIGNED f <br /> TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY --•--- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III .FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ._%Z7-7—A3 <br /> —'A3 <br /> CALL FOR A GROUT INSPECTION,PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 w 7/72 1M ° <br />