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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephond: (204) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> S � <br /> THIS PERMIT EXPIRES 1 YEAR FROM TATE ISSUED Date Issued b'-/ - 7 2- -: <br /> (Complete In Triplicate) <br /> Application is hereby a 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 nd the "Rule and Regulations of the San 3oaquin Local Health District. <br /> JOB ADDRESS/LOCATION / CENSUS TRACT <br /> Owner'.s Name + � , . .� Phone <br /> Address r :* h City <br /> Contractor's Name OJI � r -� : „ .� ` "� � '� License #:!%��/7�2hone <br /> r <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /,"RECONDITION DESTRUCTION 17 <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _IG Cable Tool Dia. of Well Excavation �* <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type-of Grout <br /> Other Other Information __ - k/ ': :� .,— f <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: r / / State Work Done <br /> PUMP REPAIR: / / State Work Done .. <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply_rwith 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 /> SIGNED TITLE <br /> (DRAW PLOT.PLAN •0 ' REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY TE l <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE f �� U <br /> CALL FOR A GROUT INSPECTION PRIOR TO .GROUTING AND FINAL INSPE <br /> E H 1426 4/72 IM <br /> s <br />