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C� v <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION y y l CENSUS TRACT <br /> Owner's Name Phone <br /> Address O . ` City ycr� <br /> Contractor's Namer' License 1/�� Phone <br /> r <br /> TYPE OF WORK (Check): NEW WELL /T DEEPEN /-7 RECONDITION /-7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR J37 PUMP REPLACEMENT /-7 <br /> Other /—/ T " <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �1 <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 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP REPAIR: )5� State Work Done <br /> F <br /> ,,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 /> information s true to the best of my knowledge and belief. <br /> SIGNED L TITLE 45� <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B /2, <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OPAT tIPISPWTION/ PHASF,,gIIFINAL INSPECTWN <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />