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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Krmit No. <br /> THIS''PERMIT EXPIRES i YEAR FROM DATE ISSUED Date Issued �. 3 <br /> (Complete In Triplicate) O l - Z to 13 <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 atid' the` Rules and Regulations of the San Joaquin Local Health Di trio: ' <br /> JOB ADDRESS/LOCATION �' "*"?"fir 7r, A A110 <br /> / <br /> �:jCENSUS RACT ")- <br /> Owner's Name d Phone-?o 6h <br /> Address <br /> City <br /> Contractor's Name _ ,�Q � � License # - � <br /> c7 Phone .. <br /> TYPE OF WORK (Check) : -NEW WELL L_?" DEEPEN /_% RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 N ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC !I <br /> InduAT <br /> strial able Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �, <br /> Domestic/public Driven Gauge of Casing 01 <br /> __j,eo0 Irrigation Gravel Pack Depth of Grout Seal �-- <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 1 <br /> 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ Lii1r/. f H.P._ & <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / J State Workk `Done v } <br />.)ESTRUCTION OF WELL: Well Diameter - <br /> . Describe Material and Procedure Approximate Depth <br /> - <br /> Describe <br /> 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 /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />[NSPECTI.ON BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. • <br /> E H 1426 <br /> 7/72 1M �Ukl <br />