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A <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 PUMP PERMIT Permit No.71_ - � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate Issued <br /> (Co;rplete In Triplicate) p�7 <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. 1$6 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO � -"' � r CENSUS TRACT <br /> Owner's Name - � Phone <br /> Address ��%/ - City <br /> Contractor's Name - License 4L Phone' <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/—/ RECONDITION /�/ DESTRUCTION /? <br /> UMP <br /> PINST ATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <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 v1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> -c <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 �1 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ��pp <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 nd 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 GROUT INSPECTION PHASE TIT/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /- DATE//-X -'-7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />