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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,/_S",2/)6 <br /> d I I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3a J6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 4t and/or install the work herein described. This application is made in compliance with San Joaquin <br /> f County Ordinance No. 1862 and the Rules an2RR%e ulations of the San Joaquin Local Health District. <br /> ' JOB ADDRESS/LOCATION <br /> 40 CENSUS TRACT <br /> Owner's Name Phone <br /> k <br /> Address City <br /> Contractor's Name + License #/J! ,�'Phon <br /> TYPE OF WORK (Check) : NEW WELL Al DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSi LATION REPAIR / / PUMP REPLACEMENT /? <br /> Other / / P"1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I/Y dVW <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal V <br /> Other Rotary Type of Grout <br /> �. .� Other Other Information <br /> PUMP INSTALLATION: Contractor ` <br /> Type of PumlWorone/ H.P. <br /> PUMP REPLACEMENT: <br /> S3tate <br /> dZI -A- <br /> PUMP REPAIR: / / Slate Work one <br /> t `�, 3ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T— 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> I APPLICATION ACCEPTED,.BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION P E III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />