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/ 7�et-)r 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. I-j— <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .- -?3 <br /> (Complete In Triplicate) <br /> Application 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 in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the .San Joaquin Local Health District. <br /> Z--(v a F_ , +_11j . 2-esSIO-f3 <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Nares <br /> Phone -S-&- <br /> Address �/ �� , <br /> City �,_&�lX / <br /> Contractor's Name J�s rS� O/t � c'} License Phone .27p� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR UMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <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 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION! Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />' PUMP REPAIR: /State Work Done <br /> ,AEST_RU_ CTION 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 true to the be P <br /> t of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � f'3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />