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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 CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT<iEXPIRES l YEAR 'FROM DATE ISSUED : Date Issued 1� <br /> (Complete In Triplicate) 3. <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 Sari Joaquin Local Health District. ii <br /> sl <br /> JOB ADDRESS/LOCATION D /j/'� /t CENSUS TRACT <br /> Owners Namely /' Phone <br /> Address /7 a City <br /> 1♦ <br /> Contractor's Name cense It ,Z Q,(Mbne <br /> TYPE OF WORK (Check) : NEW WELL -/0 DEEPEN '/—/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> �u <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER Y�NFS PIT PRIVY <br /> SEWAGE DISP AL FIELD jb CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE ELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> =.-�Domestic/private Drilled Dia. of Well Casing 46dl <br /> Domestic/public Driven Gauge of Casing 72 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> -- <br /> Other Other Informatio <br /> l; <br /> PUMP INSTALLATION: Contractor <br /> i' <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /_/ State 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 /> atter 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 trueto the best of ,ry knowledge and belief. <br /> SIGNED TITLE �-/ <br /> (DRAW PLOT PLAN ON REVERSE SI ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHA II GRO T INS TIOIJ PHA II /FIN INSPECTION <br /> INSPECTION BY DATE INSPECT ION BY DATE I o7 �/ <br /> CALL FOR A GROU INSPECTION PRI TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />