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FUR SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7j-- <br /> THIS PERMIT'EXPIRES 1 YEAR FROM DATE ISSUED <br /> # Date Issued, <br /> {Complete In Triplicate) i <br /> Application is hereby made to 'the San Joaquin Local Health District for a permit to construct J <br /> and/or install the work herein described. This application is made in compliance with San Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. + <br /> f <br /> JOB ADDRESSAOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> �. City <br /> Contractor's Name <br /> Licenv Phone -Z_-/-3 <br />-TYPE-OF-WORK Check) ; NEW WELL DEEPEN RECONDITION /? DESTRUCTION /-7 <br /> PUMP INSTALLATION <br /> Other / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> DISTANCE TO NEAREST; SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT t <br /> � OTHER � <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS 1 <br /> � ble Tool Dia, of Well Excavation v <br /> Domestic/private Drilled Dia, of Well Casin <br /> Domestic/public g <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal N <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of ;Pump <br /> H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP.REPAIR: /`/ .ta:te_Work-Done-- - <br />)ESTRUCTION OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San`Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter Completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />►ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. <br /> IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> RASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED By <br /> DDITIONAL COMMENTS: DAT Ef' <br /> 4 <br /> PHASE II GROUT INSPECTIO _ <br /> 0PECTION BY PHASE III FINAL INSPECTION <br /> DATE /dr. INSPECTION BY ` DATE 3 �S <br /> CALL FOR A GROUT INSPECTION PRIOR TO -GROUTING AND FINAL INSPECTION. <br /> EH ,1426 <br /> 7/72 IM <br />