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r � �N F. .Y •� _ f <br /> 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. _qy,_p a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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 /> /�- / CENSUS TRACT <br /> JOB ADDRESS/LOCATION O I� h- <br /> ' <br /> Phonec"�' i [ <br /> Owner's Name i L� <br /> 1 <br /> Address 2 �- . City . <br /> % License # f�f �o Phone /7;?)L r <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_T DESTRUCTION I-7 <br /> PUMP INSTALLATION / PUMP'REPAIR N7MP PUREPLACEMENT I-T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />` SEWAGE DISP6:41OS FIELD _ ---' :CESSPOOL/SEEPAGE PIT OTHER �+ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> f <br /> rivate Drilled Dia. of Well Casing <br /> Domestic/private <br /> Domestic/public Driven Gauge of Casing <br /> kIrrigation Gravel Pack Depth of Grout Seal <br /> ` Other Rotary Type of Grout <br /> . Other Other Information <br /> C PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump r cp <br /> t PUMP REPLACEMENT: / / State- Work Done <br /> PUMP REPAIR: State Work Done <br /> i e Approximate Depth <br /> �IESTRUCTION OF WELL: Well Diameter , <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 :£ California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> r 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 i . true to the best of my knowledge and belief. <br /> t <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ' <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE II SINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY.' 1 DATE <br /> CALL FOR A GROUm INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 lM <br /> E H 1426 <br />