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`! 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 /> Application is hereby made to� the San( mple a In Triplicate) 'D . f -1 M-,Ov <br /> q Local Health District for a permit to construct <br /> and/or install. the work herein Jodescribed. 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 /> Z7_7V <br /> JOB ADDRESS/LOCATION �� CENSUS TRACT S <br /> Owner's Name <br /> F <br /> Phone <br /> Address d 6 <br /> City <br /> I <br /> Contractor's Name ' License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /—/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / ,/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> rc <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (� <br /> t <br /> INTENDEDUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .Industrial J Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled <br /> Dia, of Well Casing <br /> Domestic/public I, Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal - <br /> Other i Rotary Type of Grout <br /> I Other Other Information <br /> I <br /> PUMP INSTALLATION: Contractor E <br /> Type of1Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP REPAIR: / / State Work Done <br /> 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 I <br /> JELL 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 wledge and belief. <br /> s <br /> iIGNED ! TITLE <br /> (DRAW T N REVERSE SIDE <br />'RASE I <br /> FOR DEPARTMENT USE ONLY <br /> n <br /> XPLICATION ACCEPTED BY A DATE = -�-' <br /> LDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I /FINAL INSPECTION <br />:NSPECTION BY DATE INSPECTION BY DATE <br /> 07. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />