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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 /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22-W <br /> f <br /> THIS PERMIT EXPIRES •1 YEAR FROM DATE 'ISSUED , Date Issued- <br /> (Complete In Triplicate) n <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 /> JOB ADDRESS/LOCATION 11.7 0 e, L./1 ,/CENSUS TRACT ' <br /> Owner's Name Phone ' • OJ'? - <br /> Address 0 0' �„� )-ne, City , <br /> Contractor's Name License # j' ?3 Phone , J� <br /> TYPE OF WORK (Check) . NEW WELL/ / DEEPEN '/ . RECONDITION /_� DESTRUCTION /_7 <br /> PUMP INSTALLATION /. / PUMP REPAIR/ / PUMP REPLACEMENT /TT <br /> Other <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 '" Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing j <br /> Irrigation ; Gravel Pack Depth of Grout Seal . � <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> IT\. . <br /> 4 5. <br /> PUMP' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> F <br /> PUMP REPLACEMENT: ,f / State Work Done <br /> State-Work Done - - - <br /> PUMP=REPAIR: --�`--::._ /%,._ --�-- <br /> ESTRUCTION OF WELL. Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> k 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 :w rk 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 /> 4 - <br /> r, (DRAW PLO PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C DATE a a. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />