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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1bC�' E. Hazelton Ave. , Stockton, Call �. <br /> Telephone: (209) 466-6781 k .� <br /> APPLICATION FOR WELL CONSTRUCTION''OR P PE IT No. 30 <br /> THIS PERMIT EXPIRES 1:YEAR'FROM.DATE -ISSUED, Dat Issued - v <br />�. .(Complete In Tripl:i-cate) <br /> Application.is :hereby:: made-:to .the San-:Joaquin .Local Health Di.strict. for..a permit,to -construct <br /> and/or install the work herein described. This.appl.icati:on•is uade .in ,compliance with San Joaquin <br /> County Ordinance Nai .1862=and !the Rules andi•Regulations'.-of the. San Joaquin-Local Health District. <br /> JOB ADDRESS/LOCATION 4Nkk CENSUS'.TRACT <br /> Owner's Name Phone <br /> Address <br /> i ,City <br /> Contractor's Name License �� jZ��Phone7 r-� . <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN / / RECONDITION DESTRUCTION /-7 <br /> i PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> i Other /. ./ <br /> DISTANCE TO NEAREST: SEPTIC TANK OC SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ..TYPE OF LL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation _ # <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> i Irrigation Gravel Pack Depth of Grout Seal T - <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: ` 'Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 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 ag a to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Sta a 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 TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED / DATE p f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> -TION BY DATE INSPECTION BY DATE <br /> JRA GROUT INSPBCTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 426 4/72 1M <br />