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SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOR OFFICE USE: 11501 E. Hazelton Ave. , Stockton, Calif: <br /> Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '� In/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �3 <br /> :t (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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distract. <br /> JOB ADDRESS/LOCATION -tom CENSUS TRACT <br /> Owner's Na1me° Phone <br /> Address ' . City <br /> Contractor's Name Q- i�_S I eG License # 2402 <br /> Phone17 <br /> TYPE OF WORK (Check) : NEW-WELL�ZW' �DEEPFN`- / RECONDITION-/_ ­DESTRUCTION 1-7PUMP,,INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other' <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES PIT PRIVY <br /> 1 SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 7.f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f Industrial 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public j Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �l <br /> Other j 1 ( Rotary Type of Grout G_4AY :: - .6MT"1, N 1 i <br /> .1 Other Other Information <br /> PUMP INSTALLATION: Contractor 1. <br /> Type ,1of' Pump H.P. <br /> PUMP REPLACEMENT: / / ;State Work Done <br /> PUMP REPAIR: ' - <br /> i � / / 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 /> WELL DRILLERS REPORT of the ;well and notify them before putting the well in-use. The above <br /> informattrue to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY, , _ <br /> DATE <br /> J ADDITIONAL COMMENTS: _ E <br /> PHASE II GROUT INSPECTION P E iiLI Y INSPECTION <br /> ' INSPECTION BY DATE INSPECTIO DATE /� <br /> a <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> # E H 1426 7/72 1M ys <br /> F., <br />