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ZSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.- F CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � t_J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��3 <br /> ` (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit 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 /> -- <br /> Owner's Name Phone . <br /> Address / l -12-10 City Aame,kz <br /> s Contractor's Name License # 142 PhoneD <br /> TYPE OF WORKCheck) : NEW WELL / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7( PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / '' '� •� e <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIAES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD' ` t. CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED -USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> k _ Domestic/private Drilled Dia, of Well Casing I" j? j �,,p[� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea' _ <br /> Other Rotary Type of Grout dyar _ __- <br /> Other Other Information <br /> h <br /> PUMP INSTALLATION: Contractor <br /> Type 6f Pump H.P. <br /> I PUMP REPLACEMENT: / / State Work Done <br /> PUMPIREPAIR: / f State Work Done <br /> i .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 /> j 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 /> f SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ` <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASF, 11 GROUT INSPECTION PHA II INAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GRO INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> 7/72 1M <br /> E H 1426 <br />