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SAN JOAQUIN` LOCAL HEALTH DISTRICT <br /> l'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 /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete .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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San ,Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT -- <br /> ,,9n1 a <br /> Owner's Name �J Qr1'1- �k � � _ Phone <br /> C7 <br /> (Address � � � City <br /> Contractor's Name ?� License #,;�fwl(Jj� Phone <br /> (TYPE OF WORK` (Check).: NEW WELL /V <br /> DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION L' PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY nn'' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Y <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> �. Industrial Cable Tool Dia, of Well Excavation C <br /> �Iv! Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> .11. Irrigation, Gravel Pack Depth of Grout Seal <br /> it Other Rotary Type of Grout <br /> Other Other Information - <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> Il — <br /> P;UMP REPAIR: J / r State Work Done <br /> I� <br /> ,� STERUCTION OF WELL: Well Diameter <br /> _. Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> Ithereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californiafpertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion a' my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of thelwell and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> Sit GNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> �. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT .INSPECTION PHA54 I FINAL INSPECTION <br /> INSPECTION BY ILN DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE N. <br /> f <br /> E H 1426 7/72 1M <br />