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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 PERMIT Permit No. ���/0 7 <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5-/ <br /> ! - (Complete In Triplicate) <br /> Application is hereby made tdithe 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 andthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , CENSUS TRACT ' <br />,`Owner's Name , '`-- <br /> Phoner - <br /> Address City <br /> Contractor's Name t . t <br /> U License # Phone <br /> t <br /> TYPE OF WORK (Check): NEW WELL /17---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 /> x SEWAGE DISPOSAL FIELD,.,, . CESSPOOL/SEEPAGE PIT OTHER � <br /> INTENDED USE TYPE OF WELL __ ,. CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 Cable Tool -Dia, of Well Excavation <br /> ',' Domestic/private f Drilled 44a.. of Well Casing <br /> Domestic/public Driven Gauge of- Casing <br /> Irrigation 'ravel Pack Depth of Grout Seal 1�9 44 <br /> Other otary Type of Grout <br /> Other O'ther Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP REPAIR: _ .� <br /> State Work Done , <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 j <br /> WELL DRILLERS REPORT of the well and notify themilbefore 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 ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY , DATE <br /> ADDITIONAL COMMENTS: <br /> P SE II GROUT INS CTIO PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> e <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. C.0 <br /> a <br /> E H 1426 7/72 1M ; <br />