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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0 OFFIC US : 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 l YEAR FROM DATE( .ISSUED Date Is�suea ..�j-/�7.z; <br /> . _`. :..(Complete 'In Triplicate)Application' is hereby made-to the`San Joaquin Local.-Health District fora permit to construct <br /> and/or install the work herein-_described: This application is, made in '.compliance ;with 'San Joaquin <br /> County .Ordinaxtce No. 862 -and, Rules and Regulations of the San Joaquin. Local Health District. <br /> JOB ADDRESS/IACATION �,, `. .• ` <br /> S p�ENSUS TRACT <br /> Owner's Nage4 _ ` 41�r_ . <br /> Phone <br /> i <br /> Address , <br /> City.-.. <br /> Contractor's Name _ (/ft_ .:�Li"cense� _ - r'Phon - <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / RECONDITION /_7 DESTRUCTION 1-7 { <br /> PUMP INS CATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LPWS PIT PRIVY <br /> SEWAG JIISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INT9NDED USE TYPE -OP WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialIL Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation 1 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: / / State Work Done <br /> PUMP REPAIR: / / State Work. Done <br /> ESTRUCTION 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 any work on ,a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well a notify them before putting the well in use. The above <br /> information i rue to the best o my knowledge and belief. <br /> SIGNED TITLE �. <br /> (DRAW T PLAN ON REVERSE SID <br /> R DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY �. DATE3- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE <br /> �I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION-PRIOR -TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M tC1/ <br />