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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: -' Ir 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 <br /> (Complete In Triplicate) <br /> Application isliereby 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 /> Q' <br /> JOB ADDRESS/LOCATION C945_o CENSUS TRACT S-. 5 t <br /> Owner's Name Phone <br /> Address CSS-*tai City <br /> Contractor's Name ✓ <br /> _ License Phone <br /> ` 6-m <br />' TYPE OF WORK {Check}: NEW WELL / / DEEPEN /__7 RECON ITION /_-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /0 PUMP REPAIR / / PUMP REPLACEMENT <br /> - Other <br /> DISTANCE M-NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 0 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor gKA,_ <br /> Type of Pump H.P. -_ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCtION OF WELL: Well Diameter 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 a well and notify them before putting the well 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 __412Q, . DATE x --7 L� <br /> ADDITIONAL COMMENTS: 1 ' <br /> PHASE II GROUT INSP (( P HA4 E/1 II NAL INSPECTION <br /> INSPECTION BY INSPECTIO'N_ BY DATE S— <br /> CALL FOR A GROUT INSACTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />