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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 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 <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 /> J0� ADDRESS/LOCATION o01 CENSUS TRACT � S tld-- <br /> k <br /> Owner's Name <br /> ...,... ....,,_..._ ._._� Phone �61 <br /> Address <br /> City <br /> —.__.. .. <br />' Contractor's NameZM.PAA> License # /.7.6 Phone <br /> TYPE OF WORK (Check) : NEW WELL LV DEEPEN /-7 RECONDITION /7 DESTRUCTION /- <br /> PUMP INSTALLATION J / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Otherl/ / <br /> tda <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i x _ Cable Tool Dia. of Well Excavation <br /> K Domestic/private i Drilled Dia. of Well Casing gjf � <br /> Domestic/public Driven Gauge of Casing JA -Piz— <br /> Irrigation Gravel Pack Depth of Grout Seal6,j 1 _ <br /> Other Rotary Type of Grout <br /> I Other . Other Information <br /> I <br /> PUMP INSTALLATION: Contractor <br /> f Type o``f Pump H.P. <br /> I I • <br /> PUMP REPLACEMENT: / / State Work Done <br /> -.PUMP=REPAIR.---., -.. . ....Jr� State :.Work Done. <br /> DESTRUCTION OF WELL: Well Diameter SApproximate Depth 1,0 <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 the best of my knowledge and belief. <br /> SIGNED I TITLE <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> t <br /> FOR- DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> Z2 I <br /> PHASE II GROUT INSPECTION P E I: AL INSPECTION <br /> INSPECTION BY DATE INSPECTI DATE z, - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />