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-� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: d 1601 E. Hazelton Ave. , Stockton, Calif. <br /> (. Telephone: (209) 466-6781 <br /> PLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS .PERMIT EXPIRES-a-1 YEAR FROM-DATE ISSUED Date Issued <br /> r= .(Complete In Triplicate) <br /> Application is hereby .madeiLto 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 Joaquir <br /> County Ordinance No; 1'$62 and the Rules and-Regulations of the. San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION '! r (� T CENSUS TRACT' <br /> MOwner!s Name'' jI , . Phonen <br /> AddressCity <br /> ' ` <br /> Contractor's Name VAC ' _ ��C License hone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP. INSTAL TION PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE Pff-76---D ' 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 /> fi <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout . ,S & ow <br /> Other Other Information <br /> PUMP INSTALLATION: Cont Iractor ct, *V' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: / / . State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth /40 <br /> i <br /> Describ Material and Procedure FV Al 4a .Tu°. T++ , �v <br /> I hereby agree to comply with all laws and regulations of the SaA 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 /> infor ation is true to rhe b At of my kno ledge and belief. <br /> I, <br /> SIGN TITLE ! <br /> �' (DRA PLOT PLAN ON REVERSE SIDE)r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: S <br /> PHASII GROUT INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE p 7 INSPECTION BY DATE j - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E, E H 1426 4/72 1M <br /> C <br />