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; ��• ~:, .� � � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ;FOR OFFICE USE <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 3_/_7_ 7�4 <br /> iplic <br /> Application•is hereby made .to the San (Joaqu n Local rHealth District for a permit to constr <br /> and/or install the work herein described. This application is made in compliance with SanJoaquinI County_Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local, Health District. <br /> JOB ADDRESS/LOCATION _r <br /> I Lts' a w 6 CENSUS TRACT "(� <br /> Owner's Name LT ' , . <br /> S �.� d T Phone ' <br /> Address <br /> o ie <br /> City <br /> Contractor's Name t <br /> License # Phone <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REP CEMENT <br /> Other / / <br /> of �" <br /> DISTANCE TO NEAREST: SEPTIC TANK / <br /> SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> ' OTHER %N f <br /> INTENDED USE TYPE OF WELL "k <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> Domestic/private Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> . Domestic/public Driven <br /> Irrigation Gauge of Casing - <br /> Z Gravel Pack Depth of Grout Seal <br /> Other t Rotary Type of Grout <br /> 7 Other Other Information ' <br /> PUMP INSTALLATION: t <br /> Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP REPAIR• <br /> • State Work Done <br />,)DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin-Loc L 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 i <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the st of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR D TMENT USE ONLY ' <br /> APP CATION ACC D BY <br /> ADDITIONAL COMMENTS: DATE •-�Z— <br /> PHASE II GROU INSPECTIONt <br /> INSPECTION BY PHA II/ INAL INSPECTION i <br /> DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ' <br /> 4 E H 1426 <br /> 4/72 1M r <br />