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SAN JOAQUIN LOCAL FEALTH DISTRICT 4 <br /> FOR OFF 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I 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. 1$62 and the Rul s gC:�4- <br /> and Regulations of the San Joaquin Local Health District. <br /> � <br /> JOB ADDRESS/LOCATIONj CENSUS TRACT <br /> Owner's Name Phone <br /> Address Ol/ Cit f ( -1 <br /> Contractor's NameP� License #�j�`Oln. Phone??'7-0 <br /> TYPE OF WORK (Check) : NEW WELL/Zip--DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION-./���UMP -REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS U --SEWER LINES 0 --7-PIT PRIVY � L <br /> SEWAGE DISPOSAL FIELD�C� fi CESSPOOL/SEEPAGE PIT&d-;� OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Ind strial Cable Tool Dia. of Well Excavation <br /> omestic/private Dri-lZed bia. 6CWell Casing - <br /> Domestic/public Driven Gauge of Casing 0 <br /> Irrigation Gravel Pack Depth of Grout S 1 _I� �'j,•t•c t. tl Other Mary Type of Grout V- <br /> Other Other Information — .!-- <br /> PUMP INSTALLATION: Contractor } - y- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> F <br /> PUMP REPAIR: <br /> / / State Work Dane <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with 411 laws and- regulations of the San Joaq`izn 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 /> informer 'on is true to the t n y knowledge and belief. <br /> SIGNED k TITLE <br /> (;Z-- <br /> RAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> SE I y � � <br /> APPLI CEPTED BY DATE <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE \-� -� - INSPECTION BY DATE 5- 1 S-'JH <br /> CALL F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION, <br /> E H 1426 4/72 1M C <br />