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f 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p <br /> r�-.d Date Issued <br /> Application is _ '-��7�3 <br /> {Complete In Triplicate) <br /> hereb ► made to the San Joaquin Local Health District fora permit <br /> ct <br /> and/or install the work herdescribed. This application is made in compliancetwith nSan uJoaquin <br /> County Ordinance No. 1862 and the Rules, and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION`y <br /> ENSUS TRACT p 1 w f3D-0 <br /> ` Owner's Name <br /> Phone - <br /> Address <br /> hone `Address <br /> city <br /> Contractor's Name <br /> Licenses 6/ S qty hone 9 �16 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN€ N_/ / RECONDITION, /-j DESTRUCTION /`7 <br /> PUMP INSTALLATION /t7J�-PUMP REPAIR /�'/ PUMP REPLACEMENT /_7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY N i <br /> k- CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE � N <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well'-Excavation <br /> k--Domestic/private t Drilled Dia, of Well Casing <br /> T_ Domestic/public i Driven Gauge of Casin ` } <br /> Irrigation Gravel Pack g } E <br /> Other Depth of Grout Seal <br /> Rotary, a Type of Grout <br /> Other Other Information a, <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> _ <br /> PUMP REPLACEMENT: /�/ State Work Done — <br /> PUMP REPAIR: / / State Work Done <br />.,DESTRUCTION OF WELL: Well Diameter <br /> .. Describe Material and Procedure Approximate Depth f <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 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I } FOR nEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: } DATE <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY ✓, DATE ._ INSPECTION BY <br /> } DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />