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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES i. YEAR FROM DATE ISSUED Date Issued .��� <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO CENSUS TRACT 0-51—3570--1 <br /> Owner's Name <br /> Phone� 75,3 <br /> Address �+ <br /> �� - City �Ier� <br /> Contractor'..s_Name .O/ License 11/6.1373 Phone 3f. 1 <br /> TYPE OF WORK (Check) NEW WELL /_7 DEEPEN /�% RECONDITION /_ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR ' PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO -NEAREST: -SEPTIC TANK SEWER DINES PIT PRIVY <br /> SEWAGE DISPOSAL- FIELD e� CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 _ Cable Tool Dia. of Well Excavation x <br /> Domestic/private Drilled Dia, of Well Casing <br /> .-� Domestic/pudic Driven Gauge of Casing ! <br /> �- Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information44 . <br /> (tel <br /> PUMP INSTALLATION: Contractor �� r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />,,PUMP REPAIR. ,. - State Work Done <br /> ESTRUCTION OF WELL: Well Diameter .1 <br /> _ Approximate Depth 1 <br /> Describe Material and Procedure I ;: <br /> I hereby agree tocomply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well constructior?. 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 true to the best of my knowledge and belief.'. , <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR_DEXARTIIENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C DATE <br /> ADDITIONAL COMMENTS: IV V <br /> PHASE II GROUT INSPECTION PHASE I I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - - 70 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M (1� j <br />