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* SAN JOAQUIN LO(*_AL..HFALTH DISTRICT <br /> FL�DFS M USE: C. r 1601 E. Hazelton Ave. , Stockton., Cal-if. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �f 0 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED : Date Issued "?y <br /> (Complete In Triplicate) i . <br /> Application is hereby made to the San Joaquin Local. Health District for a'pexmit 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 the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / CENSUS TRACT- <br /> Owner's Name , - Phone <br /> Address &.t city <br /> Contractor's Name r License # X373 Phone G-.9Gs <br /> TYPE OF WORK (Check): NEW WELL'/-7 DEEPEN '/_7 RECONDITION F7. DESTRUCTION /_7 --� i <br /> PUMP INSTALLATION '/_7 PUMP REPAIR /V/ PUMP REPLACEMENT /7 <br /> Other / f <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 Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Q f <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout . <br /> Other Other Information' <br /> r � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump, R.P. r} <br /> PUMP REPLACEMENT: / / State Work Done. I <br /> PUMP REPAIR: / / State Work•Done 9 ,;.y, o ` <br /> •PESTRUCTION 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 L _M, [1 TITLE r <br /> (DRAW PLO PLAN ON REVERSE SIDE�ss <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION. ACCEPTED $Y DATE J'r <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHAS 11FINAL INSPECTION <br /> INSPECTION BY �� DATE INSPECTION BY DATE' <br /> i CALL FOR A- GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 � 4/72 1M <br />