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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel-Con­Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> / THIS PERMIT EXPIRES '1' YEAR FROM DATE ISSUED Date Issued a <br /> j (Complete In Triplicate),; <br /> '.`Dplication is hereby made to the Sari Joaquin Local Health District for a permit to construct <br /> =d/or install the work herein described. This application"is made incompliance with San Joaquin <br /> , r-4 rdinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District._ <br /> t _ <br /> JOB ADDRESS/LOCATION /,� i E � CENSUS TRACT <br /> Owner's NamePhone <br /> Address City +Fi�,,lt_ <br /> Contractor's Name �� ,mor /� }r � � License iia Phone e 3 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /-7 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 /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing N <br /> ` Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout flk <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /;;V State Work Done <br /> PUMP REPAIR: / / State Work Done t <br /> r <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 <br /> WELL DRILLER PORT of the well and notify them before putting the well in use. The above <br /> information is ru to the best of my knowledge and belief. <br /> SIGNED TITLE f <br /> -(DRAW PLOT PLAN ON REVERSE SIDE <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE aj4jgj_ <br /> ADDITIONAL COMMENTS: - - - — -- <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT ON' <br /> f.INSPECTiON BY" DATE INSPECTION BY A DATE <br /> CALLS ROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 7/72 1M - <br />