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rdlSAN 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. � C <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l 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 Joaqui, <br /> County Ordinance. No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 9� �a CENSUS TRACT <br /> i <br /> Owner's Name. . _ Phone <br /> Address ' ✓ -- -- Ci <br /> a _ ty <br /> Contractor's Name �` ��.. <br /> License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /. f DEEPEN /_/ RECONDITION /_7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1✓ <br /> f r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ industrial ^� Cable Tool Dia, of Well' Excavation �� s <br /> Domestic/private Drilled Dia. of Well Casing <br /> Irrigation lic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout -Seal _CO <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r,e,.. -_ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .RESTRUCTION 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 /> WELL DRILLERS REPORT of thwell and notify them before putting the well in use. The above <br /> informatio true o 7hest of y knowl ge and bel ef. <br /> SIGN TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE J--7 3 INSPECTION BY — DATE _ - -3 <br /> CALL POR A GROUT .INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />