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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 ry', `9 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNT PERMIT Permit No. <br /> _ THIS PERMIT EXPIRES' I YEAR FROM DATE ISSUED Date Issued <br /> Np +P�1L�4a_.:• '�. (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 /> JOB ADDRESS/LOCATION ,c, CENSUS TRACT <br /> Owners Name �e <br /> Address JD 3 <br /> City <br /> Contractor's Name License hone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 /> f c� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> y Domestic/private Drilled Dia. of Well Casing <br /> i Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal L� <br /> Other Rotary Type of Grout e444 0.1;;42�-- <br /> Other Other Information <br /> ' <br /> PUMP INSTALLATION:�. Contractor <br /> d <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> jDESTRUCTION OF WELL: Well Diameter _ _ Approximate Depth <br /> Describe Material and Procedure <br /> a <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 /> i information is true to the best of my knowledge and belief. <br /> i <br /> f SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ` APPLICATION ACCEPTED BY DATE 23 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> t INSPECTION BY �X .-.- - DATE 1Q—Az;--2,3 INSPECTION BY -�1 - DATE � - ��Y--- - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M-;:-� <br />