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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L" <br /> 77AM <br /> 1601 E. Hazeltori Ave. , °Stockton, Cal f, Ljt-)y <br /> Telephone: (209) 466-6781 <br /> i <br /> ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7 <br /> 1 <br /> RIS PERMIT'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is her made -to `the 'San Joaquin Local Health District for i -permit to construct <br /> and/or install the work herein described. This application is made in compliance with`San Joaquin <br /> County Ordinance Na. 1862 and the Rulesand Regulations of the San Joaquin Local-Health District. <br /> JOS ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name• <br /> Phone <br /> Address <br /> . ,.._ .. <br /> 1 City ac. <br /> Contractor's Name J q <br /> _ License # ZkZ3L3 Phone <br />` TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /�Y DESTRUCTION /_7 � - <br /> PUMP INSTALLATION / / PUMP REPAIR Al- PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST; SEPTICjANK ISEWER LINES PIT PR W1 <br /> zVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER 0 <br /> INTENDED USE <br /> industrial TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> t Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout tt�� <br /> f Other Other Information wJ <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: :_. <br /> / / State Work Done' <br /> PUMP REPAIR: t1l <br /> State Work Done I- <br /> al <br /> ESTRUCTIONOF 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 /> SIGNED . <br /> TITLE <br /> (DRAW LOT ,PLAN ON REVERSE SIDE <br /> OR DEPARTMENT U5E ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY C� �� <br /> ADDITIONAL COMMENTS: DATE _/ jL�`�z <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - <br /> ` DATE <br /> CALL F'OR.A GROUT INSPECTION„PRIOR TO GROUTING AND FINAL .INSPECTION. <br /> E H 1426 <br /> f 7/72 1M"' <br />