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f - * .:� � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ,,,, 1-x'1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued �z <br /> Applicat (Complete In Triplicate) <br /> ion 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 /> 5 County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT S 4 7 <br /> Owner's Name.. -- <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF.WORK (Che.ck) : NEW WELL /? DEEPEN /_7 RECONDITION /7 DESTRUCTION /`7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other Y7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELLrj <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation (� <br /> Domestic/private Drilled Dia. of Well Casing <br /> fi <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other i Rotary Type of Grout <br /> E Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ;(" ! <br /> / / State Work Dane �� d <br /> PUMP REPAIR: / / State Work Done J" <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 ;an 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 i true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS r � �� •,_ <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION • <br /> INSPECTION BY DATE �`_Zo .? INSPECTION BYf <br /> DATE - Q <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> - 7/72 1M A( <br />