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f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> { Application is hereby made �o the San -Joaqu'in Local health District for a permit to construct <br /> C and/or install the work herein described. This application is made in com�plianceiwith San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> � T <br /> co - o ro, _ <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> V <br /> I' { <br /> Owner's Nam '� .. ., Phone72 <br /> Address . -- City . <br /> Contractor's Nam i License 4ij.3Z4w:?Phone7V-�- �a <br /> TYPE OF WORK (Check); NEW WELL /� DEEPEN /`7 RECONDITION f-j DESTRUCTION /-7 f <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES PIT PRIVY Rl <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �} <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial a le Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ _ 4_j <br /> Dome is/public Driven Gauge of Casing /Ci ate.. __ _ <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout. � <br /> k Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. I <br /> k PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / " State Work Dane -•► <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 11 hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californialpertaining 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 theswell and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> } <br /> SIGNEDr '4' TITLE <br /> E (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION-ACCEPTED BYDATE <br /> . ADDITIONAL COMMENTS: I - <br /> PkiASE II GROUT' INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL, FOR A GROUT-INSPECTION .PRIOR TOGROUTINGAND FINAL INSPECTION. <br /> € E H 1426 _ 7/72 1M <br />