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- ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$. OFFTCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 anis the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone3_��/oZ'S�' <br /> Address City <br /> Contractor's Namei�rls License li Phone <br /> TYPE OF WORK (Check): NEW WELL /yK DEEPEN /-7 RECONDITION /-T DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> E Other, <br /> f <br /> DISTANCE .TONEAREST: SEPTIC TANK SEWER LINES Q PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Indusfrial Cable Tool -,Dia. of Well Excavation <br /> Domestic/private l Drilled CDia. . of Well Casing _ /b <br /> Domestic/public # Driven o Gauge -of Casing f/!,/•"� ' <br /> IrrigationX Gravel Pack '.J�!--1 Dep•-h of Grout Seal S <br /> Other r ' X Rotary Type of Gfout , (b^- <br /> .Other lbther Information <br /> PUMP INSTALLATION: Contractor / <br /> ' Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> - s - - - <br /> i <br /> -PUMP-REPAI1k-.-j,— / 7-State- Work-Done-`— - ^- - ��� •� "" " - -� <br /> z <br /> I ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i 1 Describe Material and Procedure <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. WithiA- FIFTEEN DAYS <br /> t after completion of my work 'on a new well'; I will furnish the San Joaquin Local Health-4D 6triet a <br /> WELL DRILLERS REPORT of the well and notify,them" before putting the well in use. The above <br /> information -a�ltrue to-the-best.�-6f., my knowledge and belief. <br /> SIGNED--- - � — -TITLE •�_ T_. - <br /> LOT PLAN--ONi f KVE$SE'_S <br /> } <br /> a FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEP D BY <br /> c DATE <br /> ADDITIONAL COMMENTS: <br /> ;PHASE II GROUT 'INSPECTION PACUrii NAL INSPECTION <br /> INSPECTION BY DATE' INSPECTION B14 RATE . -Z <br /> F <br /> j CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> !# E H 1426 7/72 1M <br />