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[1 -r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT. OFFICE US ': 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 Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby macre 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 Sari Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District, <br /> JOB ADDRESS/LOCATION1I - - e / <br /> X9._9- 7� CENSUS TRACT <br /> �/,��-.,.__.S�„_..,...---- <br /> Owner's Name •.1 V Phone 3 Jam _ <br /> Address City <br /> Contractor's Name j �Q C_ License # �'�PhonezC�s - ��� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other / / -- — 'b <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 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 / <br /> Other e Rotary Type of Grout ; <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUY12 REPLACEMENT: / / State Work Done <br /> PUMP '2EPAIR: /7 State Work Done <br /> DF-ITRUCTION OF WELL: Well Diameter '` Approximate Depth -=-- <br /> Describe Materia ,and Procedure <br /> j T <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 PORT of the well and notify them before putting the well in use. The above <br /> informatio rue to th Rowledge and elief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,� DATE >.�� <br /> ADDITIONAL COMMENTS: s <br /> PHASE II GROUT I► PECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATEAA���� INSPECTION BY DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �Tj <br /> E H 1426 0 5/73 lm <br />