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/1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR bFFICE USE: E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION .FOR 'WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �L ri <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued u-a <br /> (Complete In Triplicate) <br /> Application is hereby made' to the San Joaquin Local Health District for a permit to 3 <br /> construct <br /> and/or install the work herein described. This application is made in compliance with 'San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION b 5 x <br /> tnJ CENSUS TRACT <br /> Owner's Name <br /> Phone . 9'd <br /> Address <br /> ' City <br /> Contractor's Name 7 <br /> r License <br /> OU Phone ? D7 <br /> TYPE OF WORD (Check): NEW WELL / I DEEPEN 1_� RECONDITION /-7 DESTRUCTION <br /> PUMP <br /> ' PUMP INSTALLATION J J P REPAIR / upUMp <br /> Other REPLACEMENT <br /> jy' <br /> DISTANCE TO NEAREST: SEPTIC TANK ^ <br /> SEWER LINES PIT PRIVY <br /> > : SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> ! Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/private <br /> Cable Tont Dia, of Well Excavation � <br /> j <br /> Domestic/public Drilled blic Dia. of Well Casing <br /> { Driven Gauge ofCasing C+ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other •Rotary V1 <br /> ' ..Other � . Type' of Grout `''�. � <br /> Y, Other Information a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ` w` <br /> i PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR. <br /> [DESTRUCTION OP WELL: Well Diameter �'T'�: 7L y,.yam► <br /> Describe Material and Procedure Approximate Depth <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 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDX4�� <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED -By <br /> A` `TIONAL COMMENTS: DATE 2 <br /> PHASE II GROUT INSPECTION P I AL INSPEC N <br /> INSPECTION BY DATE INSPECTI0 BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. DATE _ <br /> E H 1426 <br /> -- - 7/72 lM <br />