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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: <br /> V160'1 E. Hazelton Ave. , Stockton, Calif. <br /> 11 'Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7-3-- <br /> 11 SS I <br /> a THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued, -,2/-,?J <br /> 11 (Complete In Triplicate) <br /> Application is herebylinade 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 270$ ,5 <br /> JOB ADDRESS/LOCATION ��. 'n, J Wj <br /> dM CENSUS TRACT <br /> Owner's Name <br /> j iM Phone <br /> I Address <br /> City ll� <br /> Contractor's Name !! <br /> License # 'Phone <br /> TYPE OF WORK (Check): NEW WELL `L DEEPEN /_/ RECONDITION /-7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> : Other /%,� <br /> DISTANCE TO NEAREST: SEPTIC TANK &I 10T- SEWER LINES PIT PRIVY <br /> 4 SEWAGE DISPOSAL FIELD QZ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE 'OF WELL CONSTRUCTION SPECIFICATIONS <br /> ► IndustrialI� Cable Tool Dia. of Well Excavation <br /> Domestic ( Drilled <br /> Domestic/publics �" Dia. of Well Casing <br /> I� Driven Gauge of Casing 'a O <br /> E Irrigation I Gravel Pack Depth of Grout Seal <br /> Other ' pC <br /> 11 Rotary Type of Grout <br /> I1. I10ther Other Information <br /> PUMP INSTALLATION: (Contractor, <br /> Type of Pump, <br /> H.P. <br /> E PUMP REPLACEMENT: / J State Work Done I' <br />�PUMP- REPAIR: —State Work-Done- <br /> ESTRUCTION OF WELL: Well Diameter <br /> DescrDescribe p Approximate Depth <br /> ibe MAeria,l and Procedure <br /> I hereby agree to complyliwith a11i61aws 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 /> WELL DRILLERS REPORT ofl.:the well and notify them before putting the well in use. The above <br /> information is true to the best of] my knowledge and belief. <br /> SIGNED 00 <br /> �� . Il: (DRAW PLOT PLAN ON REVERSETLE SIDE <br /> PHASE IF OR DEPARTMENT USE ONLY. <br /> i <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION E I FINAL INSPEC ON <br /> INSPECTION BY _ Lip — DATE 1[ INSPECT <br /> DATE �-- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 1 - <br /> -� <br /> 7/72 1M <br />