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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE US 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 I 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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ZRESS/LOCATION CENSUS TRACT DS 3 -Q-Qa-p3 <br /> Owner's Name , � Phone <br /> Address 'S S City �,��' <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELF, ] / 'DEEPEN 'RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUPU' REPAIRPUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES4 , , -PIT PRIVY �rr <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER T <br /> w • <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> S� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done r / <br /> _IPES:TRUCTION OF WELL: We' ll Diameter � � � � � �App*ximate 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 to the best of my knowledge and belief. <br /> SIGNED 1t t�.f'_ r I `Ll11 - 2 I TITLE <br /> (DRAW PLOT PfAN ON' REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY E•-P DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE TT GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY a^ DATE ` <br /> -,7> <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. _ <br /> E H 1426 4/72 1M <br />