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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR" FFICE USE: , "1 101 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466W-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 Loral Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui; <br /> County Ordinance No. 1862 aid the Rules and Regulations of the San Joaquin Local Health District. <br /> t <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> 4 <br /> Owner's Name z Phone ° <br /> Address 74 V Psf1 City 1. <br /> Contractor's Nance 1 License # Phone <br /> TYPE OF WORK (Check): NEW WELL / j DEEPEN /_/ RECONDITION /_7 DESTRUCTION ',/-7 <br /> AL <br /> PUMP IINSTLATION /—/ 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 /> r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation tj <br /> Domestic/private Drilled Dia. of Well Casing C <br /> Domestic/public Driven Gauge of Casing C <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 N' H.P, <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: f / State Work Done <br /> ESTRUCTION 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 is t to the b st of my knowledge and belief. <br /> SIGNED - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR NT USE ON Y <br /> PHASE I C/ <br /> APPLICATION ACCEPTED BY DATE Z Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I I FI AL INSVECTIODT <br /> INSPECTION BY DATE INSPECTION BY DATE 1113 4 222, <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC N. <br /> E H 1426 � ,�.., y� .,�,. 7/72 IM <br />