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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 PUMP PERMIT Permit No. .1 3 <br /> THIS PERMIT EXPIRES-,1 YEAR FROM DATE ISSUED Date Issued <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 andithe Rules and Regulations of the San Joaquin Local Health District. 1 <br /> JOB ADDRESS/LOCATfON CENSUS TRACT _ <br /> Owner's Name Phone - <br /> Addresstl <br /> l 3.ca City <br /> Contractor's Name License # 2A71 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /� RECONDITION` /� DESTRUCTION I-T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <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 1 2=' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal L <br /> Other + Rotary Type of Grout _ . <br /> Other Other Information , <br />� eo <br /> PUMP INSTALLATION: Contractor V1 < <br /> Type of Pump H.P. <br /> 5) <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done (h <br /> DESTRUCTION 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 /> 1 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 /> f - <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON- REV SE SIDE <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION PHAS -II/FXNAL INSPECTI N <br /> INSPECTION BY DATE f INSPECTION BY DATE 3 <br /> CALL FOR A GR INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> E H 1426 7/72 1M <br />