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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO 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 <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 /> JOB ADDRESS/LOCATION j E455� J �/� {���(`� (Z !r2 CENSUS TRACT <br /> 7 r. <br /> Owner's Name LEE DUO� Phone V 3 <br /> Address S CityI' �`f _ <br /> Contractor's Name � ����� � _ License # Phone <br /> TYPE OF WORK (Check) : . NEW WELL/ DEEPEN RECONDITION RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> a ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 7 21 CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS °S+ <br /> Industrial, Cable Tool Dia, of Well Excavation <br /> Domestic/private ! Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 13tnto a <br /> ,Other Other Information �+ <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump a H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION 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 the well and notify them before putting the well in use. The above <br /> information is e '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: AT <br /> PHASE II GR NSPECTION PHASE ;4I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL -INSPUZION. <br /> E H 1426 4/72 1M <br />