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Old N JOAQUIN LOCAL HEALTH DISTRIC <br /> FOR OFFICE USE: 166._ E. Hazelton Ave. , Stockton, Ca-_i. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Re ulations of the San Jo quin Local Health District. <br /> JOB ADDRESS/LOCATION / CENSUS TRACT <br /> Owner's Name ,f Phone <br /> Address City , <br /> Contractor's Name z�f License �i J� Phon fJj�� <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INS . i`t-ATION PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO. 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout �\ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 7 H.P. <br /> PUMP REPLACEMENT: / / State Wo Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia nd 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. s <br /> SIGNED ��' `- v.� _/� TITLES <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPART NT USE ONLY <br /> PHASE I H � <br /> l ct r <br /> APPLICATION ACCEPTED`BY - _ I�J- DATE �7- � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P III UNAL INSPECTION , <br /> INSPECTION BY DATE INSPECTION BY y Z A T E <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />