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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR gFF .CE Lis 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,t7 <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 NSUS TRACT S <br /> Owner's Name Phone,*3e9-- <br /> Address City (' <br /> Contractor's Name _2<Zk-) & <br /> icense #aY�hone _ ._..u �_ <br /> ' TYPE OF WORK (Check) : NEW WELLPALT <br /> DEEPEN -/�f RECONDITION /� DESTRUCTION /� <br /> PUMP INSATION (_j PUMP REPAIR / / PUMP REPLACEMENT /—T <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 A7 . Cable Tool Dia. of Well. Excavation Olt <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout' Seal <br /> Other Rotary Type of Grout „) <br /> Other Other Information 1 _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.. <br /> PUMP REPLACEMENT: / / State Work Done <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 Sari 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 true to the be f my knowledge and belief. �1 <br /> SIGNEDA) <br /> TITLE <br /> (DRAW ^OT PLAN ON 'REVERSE SIDE) ` <br /> OR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY a ter.f ` DATEy'�2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE S•7?— <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IN <br />