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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR ,OFFI'CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 3 <br /> Telephone:P p (209) 465-5781 <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. asP <br /> �.� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. <br /> (Complete In Triplicate) <br /> f"pli�cation is hereby made to the San Joaquin Local Health District for a permit to construct <br /> d/opr install the work herein described. This application is made in compliance with San Joaquin <br /> iunty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 4 <br /> h <br /> �B ADDRESS/LOCATION S Z CENSUS TRACT S <br /> 6 1 <br /> mems Name ` L Phone <br /> �jress Cit � <br /> City <br /> tractor's Name License 9 1 <br /> i _Z �! Phone $ y <br /> �s it <br /> SPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> r'STANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> —t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r-, 's INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS s <br /> k ;_,f Industrial Cable Tool Dia.. of Well Excavation <br /> >jDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> r '_lIrrigation Gravel Pack Depth of Grout Seal _ <br /> bt -Other Rotary Type of Grout <br /> Other Other Information p <br /> i <br /> 1_MP INSTALLATION: Contractor <br /> r 4 Type of Pump H.P. , <br /> t? REPLACEMENT: / State Work Done <br /> r_1P REPAIR: f / State Work Done <br /> STRUCTION OF WELL: Well Diameter Approximate Depth <br /> r� Describe Material and Procedure f <br /> � f <br /> -nereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> d the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> :erilcompletion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> .L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> formation is true to the be t of my knowledge and belief. <br /> r <br /> !NE DTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> _ E I i <br /> P.SLICATION ACCEPTED BY } <br /> DATE <br /> r,4ITIONAL COMMENTS: <br /> i' PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> -6PECTION BY DATE INSPECTION BY DATE <br /> 4; <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ' <br /> F A 1426 7/72 1M _ G, ' <br />