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s. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP,'-OFFICE USE:. 160,I E. Haielton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued- <br /> (Complete <br /> ssued(Complete In Triplicate) <br /> Application is hereby made- to the Saxe Joaquin Local Health District for a permit to construct <br /> and1br install the work herein described. This application is made in compliance with' San Joaqu� <br /> County. Ordinance No.,w1862' and the Rules and Regulations of e .San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> F ; <br /> Owner's Name Phone <br /> Address Cam City Gyc.R c , <br /> Contractor's Name License # �TYPhone. �I,C�L <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /-7 DESTRUCTION _ e <br /> PUMP INSTALLATION (/ PUMP REPAIR / / PUMP REPLACEMENT/-7 <br /> Other i/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER, <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFIGATIONS ; p <br /> Industrial ! Cable Tool Dia, of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation ! Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grout <br /> i Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump V H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR- /% State Work Done <br /> .2ESTRUCTIO_N OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ---------------- <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 we l, n use. The above , <br /> information is true to the, t of my knowledge and belief. ' <br /> SIGNED TITLE <br /> (DRAW PLOT FLAN ON REVERSE SID—E-7, <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � � . <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,1 DATE -� W <br /> CALL ,FOR A GROUT INSPECTION„ PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M ” <br /> • r. <br />