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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 tol 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 andithe gules and Regulations of the San Joaquin Local Health District. <br /> A6 3 p <br /> JOB ADDRESS/LOC ON Dor J CENSUS TRACT <br /> Owner's Na e <br /> Phone /d <br /> Address City <br /> Contractor"s Name License # b 2 Phone <br /> -TYPE OF WORK (Check) : NEW WELL L� .DEEPEN-/rT - RECONDITION/_7 - DESTRUCTION.-/ :r. �- <br /> "" -PUMP'INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE tb NEARS T: SEPTI : TANK SEWER Ld ,ES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i r <br /> INTENDED USE TYPE OF WELL "! CONSTRUCTION SPECIFICATIONS <br /> IndustrialX Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> i Domestic/public Driven Gauge of Casing <br /> f Irrigatiop Gravel-P&ck rt. Depth of Grout Seal <br /> Other ka.,_. Rotary TYPe of Grout . <br /> Other Other Information <br /> 11 <br /> :. ., <br /> PUMP INSTALLATION:- Contractor, ' v-- "` <br /> Type of Pump _ <br /> . .. ., ,. H.P. <br /> t PUMP REPLACEMENT: / / =State Work Done- <br /> PUMP REPAIR: / / State'-,Work Done f <br /> J ,PESTRUCTION OF WELL: —Well Diameter. - __ _ Approximate D_p'th <br /> _- .: 'Describe Material and Procedure <br /> W <br /> I hereby a comply to agree with all laws and regulations of the San Joaquin Local Health District <br /> g P Y <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 /> 4 SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> ..APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION P I NAL INSPECTION <br /> INSPECTION BY DATE INSPECTI DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M 3S <br /> E H 1426 <br /> c _ <br />