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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR - OFFIVUE-USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 r <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. y? X <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued1/ <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 worts herein described. This application is made in compliance with San Joaquin' <br /> County Ordinance No. 2862 and the Rules and Regulations 'of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA N �Q , CENSUS TRACT <br /> Owner's Namef2l Phone <br /> W 9 <br /> Address City <br /> Contractor's Nam tap 6. cense 4 -1�hone� �L:.L�'�' <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INS CATION /-717- PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> _,.:.Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 01 <br /> SEWAGE DISPOS L FIELD CESSPOOL/SEEPAGE PI.T OTHER ` <br /> INTENDED USE TYPE OF ELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. ^ r Cable Tool_° Dia. :of Well Excavation <br /> „ __ Domestic/private Drilled' ' Dia, of ,Well Casing / <br /> Domestic/public Driven 'Gauge of' Casing Z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 737 <br /> Other Other Information LC <br /> 1 <br /> PUMP INSTALLATION; <br /> Contractor , <br /> Type of Pump H.P. <br /> y <br /> _� v� l <br />:PUMP REPLACEMENT: / / State Work Dane <br /> � s <br /> PUMP REPAIR: / / 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 aTW notify them before putting 'the well in use. The above <br /> information is ue to the besto y knowledge and belief, i <br /> SIGNED , TITLE i <br /> (DRAW PLO AN ON REVERSE SID <br /> FORIVEPARTMENT USE ONLY <br /> PHASE I - ,,� <br /> APPLICATION ACCEPTED,- BY �"` �—- .-DATE " <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE Z- LI 7INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1-M <br />