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SAN JOAQUIN LOCAL HEALTH DISTRTCT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t <br /> f . Telephone: (209) 466-6781, <br /> 4 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Perm#,No. _, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'. ' : Date,.,Issued l ' <br /> (Complete In Triplicate) <br /> Application is hereby made fo the San Joaquin Local Health, District fora 0 r- 2,00 construct <br /> and/or install the work herein described. This application is made in coznpliance,with;San Joaquin <br /> County Ordinance No, 1$62. and the,TRules and Regulations of the, San"Joaquin► Loca1:F€ealth Distirict. <br /> ,T <br /> JOB ADDRESS/LOCATION <br /> r CENSUS .TRACT <br /> Owner's Name Phone77^ (o0.(f <br /> Address (' p <br /> .City <br /> I <br /> Contractor's Name License #/6 D.3 ,73 Phone ? <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other — <br /> DISTANCE TO NEAREST: SEPTIC �TANK SEWER LINES PIT PRIVY N <br /> SEWAGE ;DTSPOSAL FIELD 11 - CESSPOOL/SEEPAGE PIT OTHER ^1� <br /> E 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 f Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal. <br /> Other I Rotary Type of Grout <br /> i Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: I <br /> State Work Done - - <br /> PUMP REPAIR: ti /� State Work Done - �(•-- -- - - -.. .� _ <br /> .RESTRUCTION 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 /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true <br /> to the best of my knowledge and belief. <br /> SIGNED TITLE _ <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEb BY DATE <br /> ADDITIONAL COMMENTS: ! J � <br /> PHASE II GROUT INSPECTION _PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -- _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND .FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />