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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI.:pFFZCEUSE: 1601 E. Hazelton 'Ave. , Stockton, Calif. <br /> Telephone: . (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR .FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to construct ��s <br /> and/or install the work, herein described. , This application is made in compliance with San Joaquii <br /> County Ordinance -No. 186 fn the es Regulwti, s of the Sari Joaquin Local. health Dis4rict. <br /> ���A CENSUS TRACT. <br /> JOB ADDRESSfLOCATI N <br /> Owner's Name Phone <br /> Address L d City . . <br /> Contractor's Name L "&a, License Phone _ ' <br /> TYPE OF WORK (Check): NEW WELL _/ DEEPEN RECONDITION I I DESTRUCTION %T <br /> PUMP INSTALLATION / PLW REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST': SEPTIC TAa�K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial !— Cable Tool Dia. of Well Excavation <br /> [T Domestic/private Drilled Dia. of Well Casing <br /> t Domestic/public Driven Gauge of Casing <br />{ Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout _ 4 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump 13/'x' ^ H.P. <br /> PUTT REPLACEMENT: / / State Work Done <br /> f <br /> - PMP-7kEPAI:R::._1 S.tate-Work--Done- <br /> --- <br /> I <br /> ,DFRTRUCTION 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 ''const.ruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well., I wiZl .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 know dge and belief. <br /> 4 SIGNED TITLE -�_ � .G/ - <br /> (15RAW PLOT PLAN ON REVERSE SIDE) <br /> '.; FOR,DEPATMENT USE ONLY <br /> b PHASE I aDATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ _ DATE - r INSPECTION BY DATA -7 <br /> CALL FbR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/73 <br />