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E <br /> r <br /> SAN JOAQUIN LAICAL 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. ..� <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 <br /> 62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `� CENSUS TRACT <br /> Owner's Name Phoneelt�j e 2 <br /> Address <br /> - � � City �_/�i�;�•.. -� <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_% RECONDITION /7 DESTRUCTION /_7 J <br /> PUMP INSTLATION 4` PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / /AL <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 /> T 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 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT• / <br /> State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth LL <br /> Describe Material and Procedure <br />'I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> sand 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 wel in use. The above <br /> information is true he best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> IET <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �' " DATE _a. <br /> ADDITIONAL COMMENTS: <br /> PHASE II. GROUT INSPECTION P SE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE I <br /> CALL FOR A GROTJT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 7/72 1M <br />