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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209)Stockton, <br /> APPLICATION FOR WELL CONSTRUCTIOiN ,OR PUMP PERMIT Permit No. <br /> " THIS 'PERMIT"EXPIRES I' YEARFROM 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 Local health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _ L� S r�y4, l C' f _ Phone Ism— <br /> Address _ i� City �$ ' <br /> r� c <br /> Contractor's Name �� ��p � i License #� pPhone <br /> TYPE .OF WORK (Check) NEW WELL /� DEEPEN /_�J RECONDITION /_� DESTRUCTIONS/� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /T?' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE. OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled 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 O Siihetr 'Information <br /> t :Y j <br /> e ' <br /> PUMP INSTALLATION: Contractor 's <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /State Work Done <br /> PUMP REPAIR: ,--- — / /"- State-Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> . I� f <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the hereby.-agree <br /> 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 /> (DRAW PLOT PLAN ON REVERSE" SIDE <br /> FO iPARTMENT USE ONLY <br /> PHASE I ,_._ , <br /> APPLICATIQN ACCEPTED BY `.a7�1 <br /> . O• DATE ;2_- <br /> ADDITIONAL COMMENTS: Ji <br /> PHASE 11 GROUT ,INSPECTION ]�e <br /> NAL INSPECTION <br /> INSPECTION BY DATE INSPECTIO DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDIFINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> r <br />