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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. 75.._- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued At-1I-75' <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �/ J_ CENSUS TRACT <br /> Owner's Name �'�_ Phone �, ^• � <br /> Address City � <br /> Contractor's Name License Phone ,Z <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION e PUMP REPAIR / / PUMP REPLACEMENT IWT <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven_F Gauge of Casing <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 ao i H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,)ESTRUCTION_OF WELL: Well Diameter Approximate Depth <br /> Describe Mater al and Pro dure <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 rue 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 s' <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATA INSPECTION BY r— DATE - vr� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING` AND FINAL IN ECT N. <br /> E H 1426 � 7/72 1M <br />