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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 EXPIRtS 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 t uct <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 yD- /4tAf �. <br /> CENSUS TRACT <br /> Owner's Name Phone 3 re ?7-o <br /> Address _ -- -- City . <br /> OF <br /> Contractor's Name License Phone)4! Stj� <br /> TYPE OF WORK (Check) : NEW WELL ;P DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /7/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /_7 <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 Caging f 1) <br /> —Irrigation. - - - - Gravel-Pack.- - Depth-of Grout Seal - <br /> Other Rotary Type of Grout 6 �- <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / / State Wprk Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure j <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 /> SIGNED TITLE <br /> ,(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLYT <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2"- <br /> ADDITIONAL COMMENTS: z ' <br /> PHASE II GROUT INSPECTION PHASE III/MiAl,III/FINSPECTION <br /> INSPECTION ,BY DATE - INSPECTION BY OU 4/ DATE 7 • 7?.� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />