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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 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 <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 "`�-'_� - _ lj!1„��... CENSUS TRACT <br /> I <br /> Owner's Name Phone <br /> Address ��`y S h/ / City 17rto,4L^CrA <br /> Contractor's Name S; p License #f / 3 74"Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN-' / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /)C/ PUMP REPLACEMENT /_ <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 Cable Tool Dia, of Well Excavation- <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 S <br /> PUMP INSTALLATION: Contractor C_� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_/ State Work Done <br /> PUMP REPAIR, / / State Work Done <br /> V'- <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 knowledge and belief. <br /> SIGNEDTLE -- <br /> - - <br /> LDRAW PLOT PLAN ON I E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL,I SPECTIO <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />