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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 /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> w � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. (Complete In Triplicate) <br /> Application-is.hereb , ma -to the San. Joaquin Local Health District for a permit to construct <br /> and/or install the work he ein 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/LOCATIONJ S_ Sed D CENSUS TRACT <br /> fes_,. <br /> Owner.'s Name' ��a�������_ <br /> - -- -- ; Phone <br /> Address !F_4WE ,gp .e_Zdt . City- �a�rn1 <br /> Contractor's Name 9' License #,�26 Phone ' <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_7 RECONDITION /_7 DESTRUCTION %f <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> I <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool a. , Well Excavtion <br /> Domestic/private Drilled of Well CasingN <br /> Domestic/public Driven Ga ge of C "sing <br /> _ Irrigation Gravel Pack e th of out Seal CA <br /> 'Other Rotary pe o out <br /> Other p herInformation <br /> PUMP INSTALLATION: <br /> Contractor ,.EA V. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Do <br /> PUMP REPAIR: / / State Wor Don <br /> ,pESTRUCTI_ON_- 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 's true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ... <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE-II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 '' 4/72 IM <br />