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� � S u N1 N c1� I QY1TC <br /> SAN JOAQUIN LOCAL HEALTH DIST`RIC'T <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cal i. 5 <br /> Telephone: (209) 466-6781 _�1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. g_3 Ld <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date "Issued <br /> Complete <br /> In <br /> Application is hereby made to the San `Joaquin Local rHealth tDistrict 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 r <br /> cRNsus TRACT <br /> s _ <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name - �;��, ,� License 4t`� Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTAfLATION / / PUMP REPAIR / / PUr9P REPLACEMENT /7 <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 /> _ <br /> Industrial. -------------r <br /> Cable Tool Dia. of Well Excavation ' <br />...&Domestic/private --k-'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 /> Otherp <br /> 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 /> ESTRUCTION 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 /> 4ELL DRILLERS REPORT of the well and notify them before putting the well .in use. The above <br /> Information <br /> is true to the best of my knowledge and belief. <br />;IGNED el <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'HASE i FOR DEPARTMENT USE ONLYLPPLICATION ACCEPTED BY DATE G <br /> LDDITIONAL COMMENTS: <br /> PHASE IT _QRPUT INS ECTION PHASE I /FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 7/72 1M <br />