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t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTR15CTY69 OR PUMP PERMIT Permit No. T,3-� <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 and the Rules and Regulations of the San Joaquin Iroc l Health District. <br /> �4 � ��'I <br /> JOB ADDRESS/ CATION CENS TRACT <br /> Ownbr's Na (. �� ,_ _----- Phone ��' ! — <br /> Address City <br /> Contractor's Name License # d/2 Phone <br /> TYPE OF WORK (Check): NEW WELL g� DEEPEN / / RECONDITION /� DESTRUCTION /?._ _v <br /> PUMP INSTALLATION / / PUMP RE-PAIR I I PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK /4 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 /> Domestic/private Drilled Dia, of Well Casing _ , ► e... N <br /> Domestic/public� Driven Gauge of Casing /_2_ jJ4_1164. <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: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION -OFa-WELL: - > Well DiameterApproximate—Depth <br /> Describe Material and Procedure T <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 true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> I (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ; 0 DATE <br /> ADDITIONAL COMMENTS: <br /> PHA II GROUT INSPECTION PHASE Ii/FI AL INSPECTIO <br /> INSPECTION BY DATE � ?"/4 INSPECTION BY DATE <br /> CALL. FOR A GRO INSPECTION PRIG TO GROUTING AND FINAL INSPECTI <br /> E H 1426 7/72 14"- <br />