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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 ) <br /> APPLICATION FOR WELL CONSTRUCTION -OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR -FROM DATE ISSUED <br /> Date' Issued )- 31b_3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the' San ,Joaquin' Local Health District f6i 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 /> JOB ADDRESS/LOCATION- ^,� <br /> CENSUS TRACT -� <br /> Owner's Name ✓ <br /> PhoneAddress f <br /> _ 17�s� <br /> City. . <br /> Contractor's Name <br /> License �� Phone <br /> � I <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /? RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 C* <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> i Cable Tool Dia. of Well Excavation <br /> Domestic/private -1 Drilled Dia. of Well Casing <br /> Domestic/public I / Driven Gauge af. Casing <br /> Irrigation .4 Gravel Pack Depth ofNG.rout Seal <br /> Other � � <br /> _- _ 1 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: " <br /> Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: _State�Work Done, - <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth _ <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 /> in <br /> SIGNER ' <br /> . TITLE <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDS— •� <br /> PHASE I FOR D MENT USE ONLY <br /> APPLICATION ACCEPT - F r <br /> ADDITIONAL COMMENTS: ATE -z�'.•- 7� <br /> GROUT INSPECT ON P INSPECTION <br /> INSPECTION BY DATE INSPE ON B <br /> V ATE <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 7M <br />