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C ` 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 Date Issued <br /> (Complete In,Triplicate) <br /> Application is hereby,-made t 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 /> l Health District. <br /> County Ordinance No. 1862' and the Rules and Regulations. of the San Joaquin Locai <br /> JOB ADDRESS/LOCAA�ION Ir��o � IY f7_ .L ti_ _ CENSUS TRACT <br /> t i <br /> Owner's Nameul P3 <br /> Phone � <br /> e <br /> Address L _� <br /> — City <br /> Contractor's Name' ~ License # / ^Phone '7 G <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION /_� DESTRUCTION I�T <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL r' CONSTRUCTION SPECIFICATIONS <br /> Industrial f Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia: of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> . Irrigation I Gravel Pack Depth of Grout Seal. <br /> Other t Rotary Type of Grout. <br /> �- Other - _ Other InformaCioii <br /> � PUMP INSTALLATION: Contractor <br /> L Atp <br /> Type of Pump a H.P. <br /> .PUMP HE"Naval;& <br /> State Work Done <br /> PUMP--REPAIRtate..Work- Done... <br /> ! ,DESTRUCTION 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 is true to the best of my kn ge and belief. <br /> Y � <br /> S,IGNE ITLE �'�/ . <br /> (DRAW PLOT PLAN-O EVERSE SIDE <br /> F r FOR DEPARTMENT USE ONLY <br /> PHASE I 1 DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II G NSP TIO PHASE III FINAL INSPECTION <br /> INSPECTION BY ; DATE INSPECTION BY f%? DATE /V 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE6TION. 7/72 1M <br /> ' E H 1427. V. ',, = x - <br />