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SAN JOAQUI,. CAL HEALTH DISTRICT <br /> L._ <br /> FOR OFF CE USE: g 1601 E. Razeltot, Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued �y <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 Ru es and Regulations of the San Joaquin Lgcal_HHeea,l��District. <br /> e-M.4 p s� J/V /� <br /> JOB ADDRESS LOCATION / — CENSUS TRACT <br /> Owner's Name ! Phone <br /> Address City -- <br /> r <br /> Contractor's Name , License <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR ,O PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SBWgR LINES Prr- , <br /> SEWAGE DISPOSAL FIELD L/SEEPAGE IT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial CDriven <br /> e Tool Dia, of W 1 Excavation _ <br /> Domestic/private led Dia. of ell Casing <br /> Domestic/public Gauge o Casing <br /> Irrigation el Pack Depth of G ut Seal <br /> Other ry Type of Gr ut <br /> Other Other Info oration <br /> PUMP INSTALLATION: Contractor S eu e �! r <br /> Type of Pump ' e H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done n <br /> PUMP REPAIR: State Work Done fit' E400 P,"l-I <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 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 knoowledd e and elief. <br /> SIGNED ITLE <br /> (DRAW PLOT PLAN ON R ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEGI <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A UT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> E H 1426 4/72 1M <br />