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SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. j <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> # THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued CS ' <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 Joaguir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION ,� CENSUS TRACT S E <br /> x .!1 <br /> Owner's Name Phone + <br /> 's <br /> i Address - -w.- City €� <br /> Contractor's Name - LicensePhone <br /> #� <br /> z �-� -- <br /> 4 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION /- <br /> PULP INSTALLATION / j PUMP REPAIR / / PUMP REPLACEMENT /? 1 <br /> 1 <br /> Other f-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK ,!�/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL- FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _-7 <br /> r Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing _ Z /C <br /> ..__ .: <br /> Irrigation Gravel Pack Depth of Grout Seal s f <br /> Other Rotary Type of Grout <br /> Other Other Information u r . <br /> r / <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> €1 <br /> , PUMP REPLACEMENT: !j <br /> State Work Done <br /> c PUMP-REPAIR-o, -1,-/ ...State--Work Done- <br /> ,DESTRUCTION <br /> one,DESTRUCTION 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) ' E1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY ° / � -� _ -- ------ DATE E� <br /> ADDITIONAL COMMENTS: <br /> ' � y INSPECTION <br /> INSPECTION BY DATE <br /> II GROUT DATEINSPE.2 - INSPECTION BYHASE Z-f I L DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />