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r <br /> 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r ,2 <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 the Rules and Regulations of the San Joaquin Local Health District. <br /> s <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name " ; '' :_c• <br /> cf, i Phone <br /> Address .-„ <br /> City �1-�_'_'-' - � <br /> Contractor's Name U <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL /17-" DEEPEN /-7 RECONDITION /_-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /f-#'PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK f- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation fL CA <br /> ✓- Domestic/private Drilled Dia, of Well Casing 6 <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other t r "Rotary Type of Grout l <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump .'1 « H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />„DESTRUCTION OF WELL: Well Diameters Approximate Depth �< _ <br /> 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. 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-- true to the best of my knowledge and belief. <br /> SIGNED <br /> _ ... <br /> .°7 �,�.,..,�.� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIJON PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE / INSPECTION BY DATE Z <br /> CALL FOR A GR INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO <br /> E H 1426 7/72 1M <br />