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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i� Telephone: (209) 466-6781 <br /> IC APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. SGi <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' <br /> s- <br /> 1 <br /> (Complete In Triplicate) <br /> t 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 Joaquil <br /> County Ordinance No. 1862 and the Rules nd Regulations of the Aan Joaquin Local Health District. <br /> 1' <br /> JOB ADDRESS/LOCATION , <br /> f CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address ,� <br /> n City <br /> Contractor's Name License ������ Phone <br /> it � h <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -4- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S) <br /> industrial 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 <br /> Rotary y Type of Grout <br /> Other Other Information <br /> A ------- <br /> PUMP INSTALLATION: Contractor / <br /> Type of Pump H.P. <br /> ------------ <br /> PUMP REPLACEMENT: /tate Work Done <br /> Il <br /> PUMP REPAIR_: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> t 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 a ove <br /> information is true t e best of my knowledge and belief. <br /> l i1 <br /> . e <br /> SIGNED <br /> TITLE <br /> I�. (DRAW PLOT PLAN ON REVERSE SIDE <br /> I PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> `/r'' "" <br /> APPLICATION.; ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> -IC 'PHASE II GROUT INSPECTION PHASE INALINSPECTION <br /> INSPECTION BY INSPECTION BY <br /> DATE DATE G-� -- ' <br /> CALL FOR,A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />