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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. �y_ a <br /> THIS PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED <br /> I Date Issued ) <br /> Application is -hereb � - (Complete In Triplicate} <br /> Y ma'db 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 SanJoaquin <br /> i County Ordinance No. 1862• and-:the Rules and Regulations of the San Joaquin Local Health District_ ` <br /> JOB ADDRESS/LOCATION ACV U <br /> CENSUS 'TRACT $ 'Z <br /> Owner's Name ,:k � , ,� .�.• <br /> Phone•f R3 5�o SSC <br /> Address F <br /> City . 'l!/Z G'7 <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check) : . NEW WELL /DEEPEN /_/ RECONDITION /_/ DESTRUCTION _ <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Otherr4 // n /? <br /> DISTANCE TO NEAREST: SEPTIC .TANK { <br /> SEWER LINES PIT <br /> I PRIVY <br /> SEWAGE,DISPOSAL FIELD S'a, CESSPOOL/SEEPAGE PIT OTHER r <br /> � e <br /> INTENDED USE TYPE OF WELL CONSTR <br /> CATION5UCTION SPECIFI <br /> Industrial Cable Tool Dia. of Well Excavation <br /> � Domestic/private <br />�-� - Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing. 2 <br /> Irrigation , Gravel Pack Depth of Grout Seal -� <br /> Other Rotar ^� <br /> Y Type of Grout <br /> Other Other Information — <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump <br /> .H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District .1 <br /> and the State of California pertaining to or regulating well constructipn. 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 ,jg§ true to the best of my knowledge and belief. <br /> SIGNED . <br /> TITLE <br /> y (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE A&- �3 <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE II/FINAL INSPECTION <br /> DATE INSPECTION By <br /> DATE !?-'7 y "F <br /> CALL 2 6 .A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION <br /> E H 142& � . <br /> X4/72 1M . <br />