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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F"0F. 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 l YEAR FROM DATE ISSUED Date Issued ,�49-11_ 73 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or ins4all the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1€362 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> t t <br /> Owner's Nasse Phone <br /> Address a p �� � �-+v� f c, City , <br /> Contractor's Name _ License # Phone <br /> TYPE OF WORK (Check): NEW WELL ILT— LEPEN -/ / RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/—PUMP PUMP REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> Other /-7- <br /> DISTANCE <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 a Tool Dia. of Well Excavation / <br /> tic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing b <br /> Irrigation Gravel Pack Depth of Grout Seal A-K-fa�_ <br /> Other Rotary Type of Grout &<2 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> .DFRTRUCTION 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 /> SIGNEDc�Q44 <br /> 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 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY -� /�1DATE J0 -�2 $'-?-_ INSPECTION BY DATE & -,2 _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />