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SAN JOA UIN LOCAL HEALTH Ai,TH 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. <br /> c <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sara 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 d the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone , - ? ,-- <br /> Address 2 City <br /> Contractor's, Name A License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / r DEEPEN/�/ RECONDITION / DESTRUCTION /- <br /> PUMP INSTALLATION / / - PUMP REPAIR JUMP REPLACEMENT• /7 + <br /> Other / / <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES PIT PRIVY <br /> SEWAGE' DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r � t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation �f <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domes tic[public Driven Gauge of Casing <br /> �E Izrigation. Gravel Pack Depth of Grout Seal <br /> OcherA Rotary Type of Grout <br /> k i Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1 H.P. <br /> PUMP REPLACEMENt: / / State Work Done <br /> PUMP REPAIR. /a'/ State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter �� Approximate Depth 3 Sy <br /> Describe Material and Procedure <br /> • fj - <br /> I hereby agree to comply with all lawsandregulations 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 />`. informatiqki is true to the best of my knowl'edge'and belief. <br />=;SIGNED TITLE`/ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 0PHASE I #, <br /> DATE <br /> APPLICATION ACCEPTED BY .� <br /> ADDITIONAL COMMENTS: s ` <br /> PHASE II JROUT INSPECTION APE AI INAL INSPECZLON <br /> INSPECTION i'BY, , DATE INS DATE <br /> - F <br /> a` CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426, <br /> 4/72 1M <br /> - I <br />