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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No; 3-a <br /> ��T <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) 3 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct I <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 7da CENSUS TRACT <br /> Owner's Name . Phone <br /> Address S <br /> city <br /> Contractor's Name. . _ „J <br /> -'�� _ License #422=Phone. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /? DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 � ' 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 Rotar -� :a `. <br /> Rotary Type of Grout <br /> Other Other Information <br /> V5 <br /> f <br /> PUMP INSTALLATION: sfContractor <br /> Type ,of Pump H.-P, <br /> PUMP REPLACEMENT: f <br /> '/ Lf State Work Done <br /> PUMP"REP ,,. �. <br /> AIR: /mow/ .S tate Work Done <br /> PESTRUC_TION 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 �pe.rtaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joa uin Local Health District_.a <br /> WELL DRILLERS REPORT of the well and notify them before putting th '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 /> 4 <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ' <br /> kPPLICATION ACCEPTED BY DATE 6 // <br /> ADDITIONAL COMMENTS: <br /> PHA. GROUT IASPECTION P00AWINSPECTION <br />[NSPECTION BY DATE INSPECTICNBY ATE <br /> -2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M ;� <br />