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300 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'OR 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 EXPIRES1 YEAR FROM DATE ISSUED Date Issued <br /> —.W-?6 <br /> i (Complete' ln 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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> 4St- r z/ <br /> Address ,� r City <br /> ' Contractor's Name License # s Phone <br /> � 9.;�.7-71 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other 1/ / <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY <br /> SEWAGE ,DISPOSAL -FIELD - - -CESSPOOL/SEEPAGE PIT- OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> .X <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _ <br /> / / .State Work Done � <br /> PUMP REPAIR: <br /> f / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter <br /> Approxie Depth of RC1 <br /> Describe Material and Procedure ' <br /> I hereby agree to comply with all laws "and regulations of the San 3 quin L cal He 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 sive TITLE c <br /> {DRAW PLOT PLAN ON REV_ERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION PHASE I F AL INSPE IO <br /> INSPECTION BY DATE INSPECTION BY C DA <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> T/72 <br />