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{ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160.1 E. Hazelton Ave. , Stockton, Calif. r '`f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT PermitNo. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM 'DATE 'ISSUED ; Date Issued <br /> (Complete In Triplicate) A3 <br /> Applicatiori'is hereby made 'to the San Joaquin Local. Health District for a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquin <br /> County Ordinance No.,;-1862- anA6 the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION .73 j.t CENSUS TRACT _ <br /> f: <br /> Owner's Name �g� _ _ Phone <br /> Address / - City <br /> Contractor's Name License �� ��237� Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /�/ PUMP REPAIR '/ / PUMP REPLACEMENT /-7 <br /> Others <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 t Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation 7 Gravel Pack Depth of Grout Seal I <br /> Other I Rotary Type of Grout <br /> .I Other Other Information ' <br /> I <br /> '1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP REPAIR: / /-- state Work Done rt <br /> gv <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth leo` <br /> - -- - <br /> Describe Material and Procedure &e! f <br /> d' i <br /> I hereby agree to comply with all 1a s nd regulations o 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 <br /> (DRAW PTMT PLAN ON REVERSE SID <br /> } OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR SPE ON PHASA III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ?,Z23. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. <br /> E H 1.426 '��_ 4/72 IM <br /> fi f/ <br />