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SAN. JOAQUIN LOCAL HEALTH DISTRICT I <br /> FOR OFFICE USE: J/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466 .6781 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 15,e <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. 1 <br /> 17 <br /> JOB ADDRESS/LOCATION �� 7 (� - �/ 0 '6 CENSUS TRACT <br /> Owner's Name Phone = " <br /> Address 14 4.V City _ [t�� <br /> Contractor's Name r^,� 4 G-,✓� J _ _ License # 0&)Phone � <br /> TYPE OF WORK- (Check) : NEW WELL /�/ DEEPEN /7 RECONDITION /T DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> TINTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial•- Cable Tool Dia. of� Well Excavation y <br /> Domestic/private Drilled Dia. of Well CasingA*,g Domestic/public Driven Gauge of Casing T . � <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: - " """' / 'SEdte-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 /> f information is true to the best of my knowledge and belief. <br /> i <br /> ad <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> G APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SF/ IIVFAAkL INSPECTION <br /> INSPECTION BY DATE INSPECTI N BY / � DATE r - <br /> { CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 8`Hrl4zfi • _ 7/72 1M <br />