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d <br /> 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 PUIY PERMIT Permit No. oC-� <br /> t <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED Date Issued <br /> I - , (Complete In Triplicate) , i <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 f <br /> e Rules and Regulations 'of the San Joaquin Local HealthS � <br /> County Ordinance -No. 1862 and ,th <br /> JOB ADDRESS/LOCATION / f 1" CENSUS TRACT <br /> ' y Phone <br /> Owner's .Name <br /> City <br /> Address <br /> LicenseL21Phone ,! a <br /> Contractor's Name t <br /> TYPE OF WORK (Check) : NEW WELL ,4;_ DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> - PUMP' INSTALLATION /'/ PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other 1 / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER J <br /> INTENDED USE TYPE-OF WELL -� . . ._ CONSTRUCTION 'SPECIFICATIONS <br /> _ Industrial ,s Cable ToolDia. of Well Excavation (' <br /> Drilled Diu. of Well Casing <br /> Domestic/private Driven Gauge of Casing /d ' <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal (- <br /> Other Rotary Type of Grout �S^C <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor = ` <br /> Type of Pump clr / ' � ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> S.ta.te,_Work: Done <br /> . PUMP REPAIR: __ ---- .. ��/, - - <br /> k <br /> DESTRUCTION OF WELL: We11 Diameter Approxi a Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations the San Joaquin Local Healt District <br /> and the State of California ,pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my workfon 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 ONLY <br /> PHASE I DATE /0 -�- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE /-/. K`7 <br /> INSPECTION BY DATE ,/ /�- INSPECTION BY /�.� r. <br /> CALL FOR A .GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 r <br />