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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. Hazeiton Ave; , Stockton, Calif. <br /> Telephone: (209) - 466-6781. <br /> PLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT Permit No. 72-- 71 <br /> THIS PERMIT EMPIRES 1 YEAR.FROM DATE ISSUED ;: Date Issued -J - 7 <br /> - (Complete In Triplicate) <br /> Application�,is�hereby in$dexto '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.• ..862.-andrthe: Rules!;and -Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONf <br /> CENSUS TRACT,�5—t <br /> Owner's 5 Name :i Y , <br /> �5, r - � � : ftp � f, ? Phone <br /> Address <br /> City <br /> _ . <br /> Contractor's Name of License # Phone <br /> TYPE OF WORK (Check) : NEW WELL_ DEEPEN/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / UMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other /_7 <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 lj! <br /> dustrial- Cable Tool Dia. of Well Excavation X- <br /> Domestic%private' ✓Drilled Dia. of Well Casing <br /> Domestic/public' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , H.P. <br /> PUMP REPLACEMENT: / / State Work Done 4 <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: . Well Diameter Approximate Depth <br /> t.. ~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 we11; I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify "them before putting -the-well ill-use. The above <br /> information is true to the best of my knowledie and belief. <br /> SIGNED Y TITLE <br /> (DRA2PLOT PLAN ON REVERSE SIDEFOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> F DATE <br /> ADDITIONAL COMMENTS: [ <br /> PHASE II GROUT INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BY ,-,-? DATE i INSPECTION BY DATE <br /> CALL_ FOR A GROUT- INSPECTION PRIOR-TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ' . .4/72 ' IM <br /> CO- <br />