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�1� w 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. <br /> THIS$ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Health a ct <br /> Application is hereby made to�the <br /> esSan <br /> Joaed.quin <br /> Lo <br /> and/or install the work herein dapplicationDietmade lnrco pliancetwithit nSanuJoaquin <br /> the Rules and Regulationsf the San Joaquin Local Health Diatrict. j <br /> County Ordinance No. 1862 and <br /> '1 LeaLCENSUS TRACT <br /> JOB ADDRESSJLOCATION <br /> Sec. , Phone <br /> Owner's Name r <br /> Address d <br /> 11? 444 City <br /> . ` License `� Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP'REPAIR N7 PUMP REPLACEMENT <br /> Other Ll 1 <br /> _ 3_11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 1114 <br /> SEWAGE DISPO FIELD " :CESSPOOL/SEEPAGE PIT OTHER G <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> E <br /> rivate Drilled Dia. of Well Casing <br /> Domestic/private <br /> Domestic/public Driven Gauge of Casing <br /> ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ` Other Rotary Type of Grout <br /> f — Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor ' r H.P. O <br /> ` Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> v <br /> PUMP REPAIR: State Work Done <br /> *r Approximate Depth <br /> ESTRUCTION OF WELL: Well Diameter _ <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 i true to the best of my knowledge and belief. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> J FOR DEPARTMENT USE ONLY <br /> PHASE I IDATE <br /> 1 APPLICATION ACCEPTED BY �-��% <br /> ADDITIONAL COMMENTS: I" PHASE II / INAL INSPECTION <br /> PHASE II GROUT, INSPECTION INSPECTION BY DATE <br /> INSPECTION BY,' ( DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M 0 <br /> E H 1426 J <br />