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SAN JOAQUIN LOCALS 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 /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <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 <br /> CENSUS TRACT <br /> Owner's Name <br /> t Phone <br /> Address ' <br /> Contractor's Name t <br /> - City <br /> _. License 4f,/Zjt0Phone4P )�. <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /% RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 --- <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> � CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS \ <br />_ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel, Pack Depth of Grout Seal (AI <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT <br /> / / State Work Done <br /> PUMP REPAIR: ' <br /> State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materialand Procedure Approximate Depth W <br /> C 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 /> JELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is true to the best of my knowledge and belief. <br /> r <br /> iIGNED TITLE � <br /> (DRAW PLOT PLAN ON REVERSE SI <br />'HASE I I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY F <br /> DDDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION P I F TAL INSPECTION <br /> NSPECTION BY DATE _ INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> - <br /> E H 1426 <br /> 7/72 1M <br /> r. r� .wr. awx �[fa •*�.7'R�v:.rw'Y-w g ka,rr +� ^'�q.axi...g, i ron <br />