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t ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone (209) 466-6781 <br /> APPLICATION FOR WELL ,CONSTRUCTION OR PUMP PERMIT Permit No,, /_21 J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (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 /> JOB ADDRESS/LOCATION (� , ,' CENSUS TRACT i <br /> i <br /> Owner's Name �y Phone - T <br /> Address City <br /> Contractor's Name License # Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /_% RECONDITION /-7 DESTRUCTION <br /> AL <br /> PUMP INSTLATION I I PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other i/_7 — <br /> DISTANCE TO NEAREST. SEPTIC TANK rSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial f 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 <br /> Rotary Type of Grout <br /> i Other Other Information <br /> 'PUMP INSTALLATION: Contractor , ', <br /> Type of Pump, <br /> H.P. ., <br /> PUMP REPLACEMENT: �+ E <br /> / / State Work Done , <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter L/�� <br /> Appr ximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 /> l� f � <br /> SIGNED { <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> - �- - - . .'.FOR,DEPARTMENT USE._ONLY-T,-... <br /> PHASE I <br /> APPLICATION ACCEPTED BY "R\,, '{-�' <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION ` <br /> INSPECTION BY DATE INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 i <br />