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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 /> PLICATION FOR WELL'CONSTRUCTTON OR PUMP PERMIT Permit No.-7- <br /> THIS PERMIT EXPIRES 1 YEAR'FROM.DATE ISSUED Date Issued - Z C Z <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 andtheRules' and egulations of tthenSan /J`oa uin Local Health District. <br /> .JOB ADDRESS/LOCATION ` f d - �� YSd ,Y CENSUS TRACT <br /> Owner's Name Phone — �� <br /> .. <br /> .Address <br /> l /�-�(.r- -.c cY City D�y� <br /> # Phone ' <br /> Contractor a Name License --- <br />'""TXPE flF WORK '(Check} : NEW"WELL /? DEEPEN /? RECONDITION /? DESTRUCTION f7 <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 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 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> .PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> i <br /> :PUMP REPLACEMENT: State Work Done <br /> -PUMP REPAIR: / State Work Done �� T <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 /> ;information is true to the est of my knowledge and belief. <br /> SIGNED TITLE <br /> k (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �J DATE <br /> ` APPLICATION ACCEPTED BY r/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III k'INAL INSPECTION �s_ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E-H 1426 <br />