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.� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif . j <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No4,7-f L � <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 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT 00-5- 170-09' <br /> JOB ADDRESS/LOCATION v <br /> Owner's Name . Phone3 <br /> Address 3 d City 6_1 <br /> Contractor's Name License ��/ 373 Phone3 .� <br /> r <br /> TYPE-OF,WORK (Check),:—NEW- WELD/ / DEEPEN /7 ""RECONDITION/_� -DESTRUCTION <br /> AL <br /> PUMP INSTLATION PUMP REPAIR � PUMP REPLACEMENT /_ <br /> Other J / <br /> a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 /> Domestic/public Driven Gauge of Casing Awe <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other ' Other Information <br /> PUMP INSTALLATION: Contractor .cr <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done Q �J <br /> PUMP REPAIR: _ State .Work Done A-- <br /> .DESTRUCTION 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 /> information is.. true to the best of my knowledge and belief. <br /> SIGNEDi TITLE, <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> a FOR DEPARTMENT USE ONLY <br /> PHASE I �` <br /> APPLICATION ACCEPTED BY DATE 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GA9UT INSPECTION PHASE II FINAL INSPECTION <br /> ` INSPECTION BY DATE INSPECTION BY DATE <br /> _ � r <br /> CALL FOR A GROUT 15PECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />