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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.T sGS'"4J <br /> k THIS PERMIT EXPIRES 1 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 Joaquint <br /> County Ordinance No. 1862 and the Rules an Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION C CENSUS TRACT <br /> Owner's Name " PhoneM <br /> Address ° _ � <br /> �) `� i�, City �• <br /> V <br /> Contractor's Name ''PLicense #d2,ff;)1Phone f ! ^' q <br /> r` <br /> TYPE OF WORK (Check); NEW WELL / DEEPEN /_7 RECONDITION,'/_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / % PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK &Pkk1SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL PIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing X d <br /> Domestic/public Driven Gauge -of Casing _ __7 Q <br /> - IrrigationA Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump 0022114Ar— H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> _. ItAj . <br /> a. a <br />.pESTRUCTION OF WELL: Well DiameterApproximate Depth I <br /> Describe Material and Procedure i_F <br /> k <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 welll'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 fiest of my knowledge and belief. �. <br /> SIGNED TITLE <br /> l <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FOR <br /> IDE) -FOR DEPARTMENT USE,ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY C � I? DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION j; PHASE IIT FINAL INSPECTIO :: j <br /> INSPECTION BY DATE INSPECTION !1Y BATE`; ' <br /> CALF FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. <br /> E H 1426 7/72 <br />