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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. � <br /> j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7J <br /> I (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 R 1 and Regulations of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name F � <br /> + Phone <br /> Address 311 City�Q-d��� <br /> Contractor's Name License # <br /> *O Phone Z <br /> ao (fes <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /? DESTRUCTION /_ <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /L{� <br /> Other /_7 <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 t Cable Tool Dia. of Well Excavation . <br /> Domestic/private Drilled Dia. of Well Casing r� <br /> Domestic/public + Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _- _ Other Rotary Type of Grout <br /> E Other <br /> Other Information <br /> PUMP iNSTALLATIONs Contractor <br /> Type of Pump <br /> H.P. / <br /> PUMP REPLACEMENT: I <br /> /� State Work bone <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> A <br /> I hereby agree to comply with-fall 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 t best of my knowledge and belief. { <br /> SIGNED <br /> �4 <br /> TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M ` !. <br />