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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.7'�/w <br /> r <br /> ;THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Bate Issued .LL <br /> (Complete- In Triplicate) <br /> Application is hereby -madi 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 Joaquj <br /> County Ordinance No. 1862 and the Rules and' Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONCENSUS TRACT S q <br /> Owner's NameZ. <br /> Phone <br /> Address All �. r _ _ City04C A-All 40 Q" <br /> Contractor's Name ti License # Phoney <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> ` PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK -7'E SEWER LINES . " PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I OC <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> E Industrial p< _ Cable Tool Dia: of Well Excavation r1z,4 <br /> Domestic/private Drilled Dia'. of Well Casing ok, _ <br /> Domestic/public Driven Gauge of Casing tp A <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 H.P. <br /> E <br /> PUMP REPLACEMENT: / / aState Work Done <br /> PUMP REPAIR: / ./ kState Work Done- <br /> ESTRUCTION OF WELL: :___WelliDiameter -- Approxaimate 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 true to the best of my knowledge and belief. <br /> SIGNED -. TITLE _per <br /> (DRAW PLOT PLAN ON REVERSE SID -- _- <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I <br /> APPLICATION ACCEPTED BY .J i DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE- III/FINAL INSPECTION <br /> INSPECTION BY DATE .. Z,T INSPECTION BYJ*/� �� DATE 2-� - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />