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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'" OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �#- S 4) <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 � d �� of, e S,an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Ll <br /> Owner's Name Q Phone <br /> {Q <br /> Address c ` City <br /> Contractor's Name Zi_ C License A"27Z one 9/;i V-3 <br /> TYPE OF WORK (Check) : NEW WELL / D EPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 (311 <br /> Other / / L?` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 0 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ale Tool ' Dia. of Well Excavation ' <br /> _A.=-Demestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 4 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout --2e _ <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 /> ESTRUCTION OF WELL: Well Diameter <br /> � Approximate 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 <br /> .. � _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ � DATE cq/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY F42r DATE IhIl7il INSPECTION BY DATE / 3 <br /> CALL FOR A. GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />