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SAN JOAQUIN LOCAL HEALTH 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. 1lJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued���T4 <br /> (Complete In Triplicate) 00 �r7 <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 ,/ CENSUS TRACT <br /> Owner's ,Name <br /> Phone <br /> Address „2� ae. City <br /> Contractor's-Name License #�9.�6�( Phone 7.�5' /a�T Iv <br /> . - <br />` TYPE OF WORK (Check) : NEW WELL / / DEEPEN /V RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP., REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <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 1=--Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of •Well Casing <br /> Domestic/public Driven Gauge of Casing 16 <br /> (/Irrigation _Gravel Pack -4 Depth of Grout Seal tv 47 �-" <br /> Other ' Rotary Type of Grout <br /> Other W Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />. PUMP REPLACEMENT. / / State Work Done <br />-PUMP-REPAIR.: - /7/ State Work Done - <br /> ECTION OF WE : Well Diameter <br /> � STRUWELL: 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 Loca1 'Health Distrite a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of .my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN-'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /,2- 7y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIJ/FINA_L INSPECTION <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 />