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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO 0 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7�J 9�/1/ <br /> /o G 7 ,8�1 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No— <br /> 1 <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 CENSUS TRACT <br /> Owner's Name ;/ ee- c Phone <br /> Address0 �� 1P�r�/Z City <br /> Contractor's Name _. r44 License <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN J J RECONDITION /_/ DESTRUCTION J-7... .._ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / J ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF ELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation Ca/� <br /> Domestic/private Drilled Dia. of- Well Casing i <br /> Domestic/public Driven Gauge of Casing ; <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Informa on <br /> n <br />' 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: J / State Work Done <br />„DESTRUCTION OF WELL; Well Diameter Approximate 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) --FOR DEPARTMENT USE ONLY <br /> PHASE I n <br /> APPLICATION ACCEPTED BY ! T /o,Az 7 � <br /> ADDITIONAL COMMENTS: <br /> PHASE JIGROUT INSPECTION PHAS INSPECTION <br /> INSPECTION BY DATE I-Z�- �- 7�2 INSPECTION BY DATE .� v <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN <br /> E H 1426 7t�l 7/72 1M <br />