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D SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0R OFFICE U 1601 E. Hazelton Ave. , Stockton, Cali-f. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_3-.A,1-y12 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued S��•3 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Loapplcal iicationalth District ra permit t <br /> made incompliancestruct Joaquin <br /> and/or install the work herein described. This PP <br /> and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules <br /> � <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION CO I q <br /> Phone 159 <br /> Owner's Nath <br /> City <br /> Address <br /> License <br /> Phone �cC7 <br /> Contractor's Name r <br /> TYPE OF WORK T(Check) :� NEW WELL / DEEPEN_/ f RECONDITIQN DESTRUCTION / <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other, / / <br /> AISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES PIT PRIVY <br /> �€ SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F INTENDED USE' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> k _ Industrial Cable Tool Dia. of Well Excavation <br /> '� Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public <br /> E Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> t — Other _ Other Information <br /> wpm <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of •Pump <br /> f <br /> PUMP REPLACEMENT-� State Work Done � •, � e,:.` -/�su <br /> � PUMP_..REPAIRo -� ��� J�/ 5tate�_Work Dane <br /> DESTRUCTION OF WELL: Well Diameter <br /> v. .ti �- Approximate Depth <br /> Describe Material,and Procedure <br /> I hereby agree to comply with all laws acid re'gulations' of' the San Joaquin Local Health District <br /> and the State of California pertaining to.,or regulating,well construction. Within FIFTEEN DAYS <br /> I~will furnish the San Joaquin Local Health District a <br /> after completion of my work on a new well, <br /> WELL DRILLERS REPORT of the well and notify them before <br /> putting the well in use. The above <br /> information is true to the best of my knowledgea <br /> nd TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASEIkIN INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE 3 <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 3/72 1M <br /> E H 1426 <br />