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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone:, (209) 466--6781 r <br /> ,APPLICATION FOR WELL CONSTRUCTION OR' PUMP PERMIT Permit No. _ �,p <br /> . THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued At-S--74' ' <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 <br /> Joaq.�inlLp,cal. Health District. <br /> JOB ADDRESS/LOCATION ! CENSUS TRACT <br /> Owner's -NamePhone _"�7 <br /> Address �� e� S /li0�U0d� /I� <br /> City <br /> Contractor's Name,- r License # Phone - <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN ' _� RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT f? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation G� <br /> Domestic/private Drilled -Dia. of Well Casing f <br /> Domestic/public Driven Gauge of Casing ; <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP REPAIR: / ./ State Work Done <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 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 �-' �� � ��y TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> s, FOR DEPARTMENT USE ONLY <br /> PHASE I ' ' � <br /> APPLICATION ACCEPTED BY � , r DATE--/-/- <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I IN INSPECT N <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL, INS CTION. <br /> E H 1426 4/72. 1M <br />