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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7` 7.7 <br /> v' (Complete In Triplicate) Oras.2.5-a-C�' <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 / ! �t�.� ' � Cep NSUS TRACT <br /> /Y,. <br /> Owner's Namefiz-r_ Phone <br /> Address �� City <br /> Contractor's Name License )3 Phone . <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /- <br /> ALf <br /> PUMP INSTLATION/ / 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 /> �7 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C� <br /> Industrial Cable Tool Dia. of Well Excavation p ' <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing S <br /> Irrigation_. . _ � Gravel Pack_ Depth of .Grout Seal <br /> Other Rotary Type of Grout .�- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done / y <br /> .DESTRUCTION OF WELL: Well Diameter _ Approxim_ate _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 /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />