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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> k1 Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7t1 sSI4-) <br /> '7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> -/r _7c� <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 CENSUS VEACT <br /> so <br /> Owner t s Name Phone�J � <br /> Address <br /> Cit i ty <br /> Contractor's Na License .3 Phone <br /> - T <br /> TYPE OF WORK (Check) : NEW WELL J DEEPEN `/-7 RECONDITION /-J DESTRUCTION /-7 <br /> PUMP INSTALLATION /fir rani REPAIR / / PUMP REPLACEMENT /-J <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 &--e9t-re-Tool Dia, of Well Excavation <br /> --ftmestic/private Drilled Dia. of Well Casing /0 <br /> Do tic/public Driven Gauge of Casing /C] <br /> rrigation Gravel Pack Depth of Grout Seal . .— <br /> Other Rotary Type of Grout <br /> Other Other Inf ormati4n <br /> PUMP INSTALLATION., Contractor -� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />..PUMP-REPAIR. 177- .State Work Done <br />'.)3ESTRUCTION 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 knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ,..-- <br /> PHASE II ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY F1 DATE INSPECTION.BY DATE /Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. C/ <br /> E H 1426 7/72 1M <br />