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FOR OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave, <br /> Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. _? <br /> THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is harsh (Complete In Triplicate) Date Issued . 7� <br /> and/or install the wor�hereintdescribedSaaquThisin oapp3lcationcal HealtDistrict for a permit to construct <br /> County �Ordinance No. 3862 and the Rules and Regulations of the San Joaquin is made in compliance with San Joaquin <br /> JOB ADDRESS/LOCATION f 9 Local Health District. . <br /> 41 <br /> Owner's Name r CENSUS .TRACT' <br /> a <br /> Address Phones <br /> Contractor's Name City <br /> f <br /> License 4� + <br /> t _ Phone <br /> TYPE OF WORK (Check) : NEW WELL _ <br /> / DEEPEN / J RECONDITION /J DESTRUCTION /—.7PUMP. INSTALLATION / / PUMP <br /> Other /, / REPAIR / / PUMP REPLACEMENT /ZT-I <br /> DISTANCE TO NEAREST« SEPTIC TANKQ r + <br /> SEWER LINES ,� � <br /> SEWAGE DISPOSAL FIELD e PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial 1 Cable Tool CONSTRUCTION SPECIFICATIONS <br />_ Domestic/private. Dia. of We11 Excavation <br /> Iti <br /> Domestic _ Drilled Dia. of Well Casing � <br /> /public Driven <br /> Irrigation F , Gravel Pack Gauge of Casing <br /> Other Depth of Grout Seal. <br /> Rotary Type of Grout <br /> Other Other Information <br /> x <br /> + <br />'UMP INSTALLATION; Contractor <br /> Type of Pump <br /> � H.P. t <br /> UMP REPLACEMENT: /I State Work Done (&W <br /> State work <br /> Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> DescribeMaterial and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />:ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />;LL DRILLERS REPORT of the wellrand notify thea before putting the well in use. The above <br /> iformation is true to the best :of my knowledge and +belief. <br />,GNED <br /> TITLE �j� <br /> (DRAW PLOT PLAN ON REVERSE -- <br /> ASE I FOR DEPARTMENT USE ONLY <br /> PLICATION ACCEPTED BY 1 <br /> DITIONAL COMMENTS: ---------- ,�' ,�f Jl/ DATE <br /> PHASE II GROUT INSPECTION L <br /> 5P$CTION BY PHASE TTI FINAL INSPECTION <br /> A, INSPECTION BY <br /> GALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPEG�TON DATE <br /> E H 1426 � a <br /> 7/72 1M <br />