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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'OFFICF USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T�� <br /> 7V--.7�° <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 /> C tyMt <br /> No. and the Rules and Regulations of the San Joaquin ocal Health District. <br /> to 0l�� 4vt �JOB ADLC/Y� CENSUS TRACT <br /> r <br /> Owner's Nance Phone <br /> Address City <br /> Contractor's Name 4& <br /> License # Phone <br /> TYPE OF WORK (Check) : NEW WELL _/ DEEPE _kRECONDITION /_7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK Y&I SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD d—D CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL.r CONSTRUCTION SPECIFICATIONS <br /> _��ndustrial Cable t of Dia, of Well Excavation 0 - <br /> Domestic/private t Dirilled,�- 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. f <br /> PUMP REPLACEMENT: / / State 'Work Done <br /> PUMP REPAIR: / / State Work Done <br />,pEST RUCTION 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 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 /> information is tr to the best of my knowledge and belief. <br /> SIGNED TITLE ? <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> AO <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 0 DATE l <br /> ADDITIONAL COMMENTS: <br /> PHASE II GB UT INS ECTION PHASE /FIN IN PE TION <br /> INSPECTION BY DATE INSPECTION BY/ D <br /> p� z_ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />