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I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton` Ave. , Stockton, Calif. <br /> Telephone_: (209):-466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f` )l�P <br /> THIS PERMIT EXPIRES%) 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 ,thO_ Rules -and 'Regulations- of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION C CENSUS TRACT <br /> ,:. . <br /> Owner's Name Phone <br /> Address City <br /> Contractor's NameGLicense �� 7 Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION I / DESTRUCTION /7 <br /> PUMP INSTALLATION / / P iP REPAIR '/ / PUMP REPLACEMENT 1_7 <br /> Other / / r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 <br /> Domestic/public Driven Gauge of Casing \4) <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of uta ' H.P. <br /> 41 <br /> PUMP REPLACEMENT: / / State War Done <br /> PUMP, REPAIR: / / State Work Done <br /> &116409"422 <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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> r 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 /> r FOR. DEPARTMENT USE ONLY <br /> PHASE i , <br /> DATE/ <br /> APPLICATION ACCEPTED BY �J- — <br /> ADDITIONAL COMMENTS: U' <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY gDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />