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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�P.ERMIT Permit No. jC <br /> ti..� <br /> THIS •PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date' Issued'.- <br /> (Complete In Triplicate), <br /> Application is hereby made'tO'-.the"San Joaquin 'Local Health Dstrict for a' permit to construct <br /> and/or install the work herein described. This application' is made in compliance wit ` San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the, San Joaquin Local Health District. � <br /> JOB ADDRESS/LOCATION / CENSifTRACT <br /> Owner's Name �_'.' . ..� >�Y . . .,.---._.,,.,_._..�..,_ 'Phone <br /> Address City.. .94—Mr"? . I <br /> Contractor's NameLicense # Phone <br /> D l <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: - SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation <br />` Domestic/private Drilled Dia. of Well Casing <br /> f Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ry� <br /> i (L- <br />', PUMP INSTALLATION:- Contractor <br /> Type of Pump H.P. <br />€ PUMP REPLACEMENT: / / State Work Done <br /> _ 1 y <br /> PUMP REPAIR: `- MJ / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f' I hereby agree to. comply with all laws and regulations of the San Joaquin Local Health District <br /> rand the State of' California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion o-f) 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 /> in- formation is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /.Z. 77 <br /> , ADDITIONAL COMMENTS: <br /> PHASE II GOUT INSPECTION ' PK4 Uvi / AL INSPECTION <br /> INSPECTION-W DATE INSPEC N B DATE <br /> CALL F'OR A.GROUT INSPECTION-PRIOR.TO-GROUTING AND FINAL INSPECTION. - <br /> E'H 1426 7/72 1M <br />