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a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z- ,3 <br /> f <br /> i <br /> TH1S PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (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 <br /> Owner's Name <br /> Phone <br /> Address �� - <br /> City <br /> Contractor's Name � .0177 01 <br /> 10 -- - _ GR9 .. License # phone �, 7.1I - .._ <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN /_7 RECONDITION /_7 DESTRUCTION _ - <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT/_7 <br /> Other / <br /> 1 <br /> DISTANCE 'TO NEAREST. SEPTIC' :TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4 . 1 <br /> _INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> _ Industrial [ Cable Tool Dia. of Well Excavation 1� <br /> >r _ Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation .1 Gravel Pack Depth of Grout Seal F <br /> Other 1 Rotary Type of Grout <br /> Other Other Information i _ �-. p� <br /> PUMP INSTALLATION: <br /> Contracltor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / J State Work Done <br />.DESTRUCTION OF WELL: Well Diameter l 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 1San 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 rue to a best of my knowledge and belief. k <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE T FOR DEPARTMENT USE ONLY f <br /> APPLICATION ACCEPTED BY .- DATE <br /> ADDITIONAL COMMENTS; <br /> /19/3/-72— <br /> PHASE II GROUT INS CTION PHA II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> E HO .�1426 7/72' 1M <br />