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1 <br /> k <br /> SAN JOAQUIN LOCAL 11EALTH DISTRICT <br /> FORrOF-FICE USE: 1601 E. Hazelt6A' AVe.`, Stockton, Calif. <br /> t , Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,73 -3,6 r4; <br /> r THIS PERMIT -EXPIRES -1"YEAR FROM, DATE -ISSUED Date Issued <br /> . (Complefe 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.41862. and-.the RulesAand Regulations of the San Joaquin Local Health District. <br /> �.�^ OS D-G� <br /> JOB ADDRESS/LOCATION -.CENSUS TRACT- <br /> L � <br /> Owner's Name"r _ :E;. r., .. :. _: Phone <br /> Address City <br /> ' Contractor's Name �G License # Phone ' 740% <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/—/ RECONDITION /DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REP IR '/ / PUMP REPNT //-7D <br /> Other LACE tn . <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 <br /> Industrial Cable .Too1 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 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor' <br /> Type of Pump H.P. <br /> iPUMP REPLACEMENT: / / State Work Done' <br /> ' .,'.PUMP REPAIR: / / _ State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I 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 /> informatjAxa, is true tt best of my knowledge and belief. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IIG N E IO PHASE tI F NAL INSPE T ON <br /> INSPECTION BY DATE INSPECTION BY �... DATE �2- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> t E H 1426 4/72 1M 31 <br />