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. "t,/'. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1170R . FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72a.4d'i <br /> r. <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE 'ISST.TED Date Issued � �O <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 and the,-Rules and Regulations of .the 'San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S -� X CENSUS TRACT q) <br /> Owner's Name o.1 •`_ Phone <br /> Address City <br /> Contractor's Name License ��.Z�/ Phone 7/ <br /> i- ITYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /? <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 _ <br /> Domestic/public Driven Gauge of Casing ` <br /> Irrigation Gravel Pack. Depth of Grout Seal M <br /> Other Rotary Type of Grout <br /> Other Other Information ' ' _ <br /> "L <br /> � PUMP INSTALLATION: Contractor ✓ ,� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> w. ;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 /> 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 knowled and belief. <br /> SIGNED R TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> F PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> .ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 1,9, DATE jE_/Y _ <br /> CALL FOR A GROUT INSPECTION PRIOR.TO GROUTING AND. FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />