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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Haxeltoi'r*K% 1-, Stockton, Calif. a <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�y-_ fs/ <br /> THI'S PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date Issued ,, <br /> { qAlete In Triplica _e) <br /> pplication is hereby "made -t6, 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 Mules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION '] CENSUS TRACT <br /> Owner's Name <br /> 'i <br /> Phone <br /> Address OIG �„ City <br /> Contractor's Name License # phone ' <br /> ffS <br /> TYPE OF WORK (Check) : NEW WELL /V-7' DEEPEN /_7 RECONDITION /7 DESTRUCTION /'7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT— <br /> Other 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 _& Cable Tool Dia, of Well Excavation <br /> Domestic/private ,��Drilled Dia. of Well Casing <br /> Domestic/public s Driven Gauge of Casing v <br /> Irrigation Gravel Pack Depth of Grout Seal :r-o <br /> Other Rotary Type of Grout _ �+ <br /> # Other { - <br /> Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> } <br /> PUMP REPAIR: `, <br /> State Work Done <br /> DESTRUCTION OF WELL: Well. Diameter <br /> Describe Material and Procedure Approximate Depth <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 /> BELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Enformation istx.,ue to the best of-my knowledg and belief. <br />>IGNED <br /> _ <br /> (DRAW P PLAN ON REVERSTITLEE SIDE <br /> CHASE I FOR DEPARTMENT USE ONLY <br />►PPLICATION ACCEPTED BYDATES <br />►DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONFHA I F NAL INSPECTION <br />:NSPECTION BYE-Ica/ ^_ DATE INSPECTION BY DATE -fie,. <br /> CALL <br /> FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />