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FO SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R OFFI; d: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> PLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. <br /> Date Issued- 6-30` 6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distri°c.t "£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/LOCATION I <br /> CENSUS TRACT <br /> i <br /> Owner's Name - <br /> Phone <br /> Address4z—/& <br /> city # <br /> Contractor's Name <br /> z <br /> License #�' Phone '��� <br /> TYPE OF WORK (Check): NEW WELL <br /> DE �/ CONDITION /� DESTRUCTION /� <br /> PUMP INS ALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /? <br /> T_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS IELD CESSPOOL/SEEPAGE PIT <br /> OTHE <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private __ Drilled Dia. of Well Casing -,:._ <br /> __...� Domestic/public Driven Gauge of Casing \n <br /> V� - <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> ` Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of. Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR- <br /> State Work Done <br /> ESTRUCTION OF WELL: Well Diameter j <br /> Describe Material and Procedure Approximate Depth ` <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health -Districts <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 /> BELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Information is true to the best of my knowledge and belief. <br />'IGNED I . . <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br />'HASE I FOR DEPARPaMENT USE ONLY <br />►PPLICATION ACCEPTED BY DATE = a <br /> JDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P NAL INSPE TION <br /> NSPECTION BY DATE INSPECTION BY. <br /> # DATES y� <br /> CALL FOR A. GROUT INSPECTION ,PRIOR TO GROUTING AND FINAL INSPECTION. _ <br /> E H 1426 <br /> 7/72 1M <br />