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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUFX PE r No. <br /> E�tPS <br /> s dTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sari -Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in -complianceiwith San Joaquin <br /> County Ordinance No.' 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION N CENSUS TRACT <br /> Owner I a Name .-��C�-+�d3 -� Ph one 9e , D _L <br /> Address ` �" - - City _ <br /> f Contractor's NameLicense <br /> f - <br /> TYPE OF WORK (Check): NEW WELL DEEPEN RECONDITION /7 DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Rl <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ale Tool Dia. of Well Excavation 1(1hn- <br /> Domestic/private Drilled Dia. of Well Casing <br /> Douce is/public Driven Gauge of Casing QCs ora^.• <br /> rrigation Gravel Pack Depth of Grout Seal I <br /> Other Rotary Type of Grout 1 <br /> Other Other Information , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> � PUMP REPLACEMENT: 1 / State Work Done <br /> PUMP REPAIR'L,D <br /> � l <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 11 hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State -of Californialpertaining 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 theiwell 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 /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> . APPLICATION-ACCEPTED BY a DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II. GROUT' INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY LE=AjL DATE <br /> CALL FOR A GROUT..INSPECTION PRIOR TO-GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />