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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6761 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquir <br /> Co un ty_rd�nance_ No 862 a d the Rules d Regul igns of the San Joaquin Local Health District. <br /> JOB ALDRESS�/jLOCAATTI=ON S4-n-X�CEDiSUs <br /> TRACT <br /> Owner's Name Phone36, Z76 <br /> Address / ' <br /> City <br /> Contractor's Name License Phone3 C a J(}-3� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /-7 DESTRUCTION /� <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / / - — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,ja N j PIT PRIVY ya e <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> d 14o(-S� Fo Q PQM jrt a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation pw <br /> T Domestic/private Drilled '� 1r, <br /> ' Dia, of Well Casing �� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal_$p <br /> Other <br /> Rotary Type of Grout <br /> Other Other Information - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumpf H.P. <br /> _ <br /> PUMP REPLACEMENT: / / State Work Done f <br /> PUMP REPAIR: / / State Work Done <br /> J)ESTRUCTION OF WELL: Well Diameter <br /> 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 hest of my know edge and belief. <br /> SIGNED TITLE c <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY V -'- <br /> APPLICATION ACCEPTED BY DATE /7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE II /FI AL INSPECTZ N <br /> INSPECTION BY �, DATE �-�Q.7tjl INSPECTION BY DATE / n <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />