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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE IJSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. <br /> THIS PERMIT 'EXPIRES `l YEAR FROM DATE ISSUED Date Issued ,,gC.;2 6 <br /> (Complete- In Triplicate) " <br /> Application is hereby made to the"San Joaquin Local Health' District .for a perseit- 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 Regul tioinpLof the San Joaquin :Local: -Health District. <br /> JOB ADDRESS/LOCATIONS <br /> sC NSUS� TRACT <br /> Owner's Name <br /> Phone <br /> Address �� _.._ <br /> City _ Y <br /> Contractor's Name - License d _' Phonkl- -.4 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION /_� DESTRUCTION /_ <br /> PUMP INSTALLATION / _ UMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / t <br /> DISTANCE TO NEAREST: SEPTIC T SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF W CONSTRUCTION SPECIFICATIONS <br /> I strial <br /> able 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 Z,60 A2 X <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> a .a <br /> PUMP INSTALLATION: Contractor ( .-i[. At <br /> ,. 'o <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State Work Done + <br /> f <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 DAY <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 true to the best o my knowledge and belief. <br /> F r <br /> SIGNED - TITLE <br /> (DRA OT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE G=/6J INSPECTION BY DATE <br /> CALL FOR A GROUT-INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION,. - 1 <br /> EH1426 ` <br /> D � .. V -//-7r 7/72 1M <br />