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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: Y 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,y- Sc S`p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-% 7171- <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 Joaquinf', <br /> County Ordinance No. 1862 and the Rut s and R lations o the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAT ON �j �� <br /> --t.�-� CENSUS TRACT + <br /> Owner's Name / <br /> Phone <br /> If Address _ ��.. / --tSJ Cit <br /> -� y <br /> Contractor's Name r <br /> .fJ' r License Phone <br />' � I <br /> TYPE OF WORK (Check). NEW WELL / DEEPEN / RECONDITION /_7 DESTRUCTION /_7 i <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> i <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 N�l <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. f , <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .RESTRUCTION 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 toQHie best of my knowledge and belief. <br /> SIGNED <br /> TITLE,7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br />` APPLICATION ACCEPTED BY DATE S <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHA§tF21,Uj2It&AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3�x- <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND'FINAL INSPECTION. <br /> E H 1426 7/72 1M P <br />