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aSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1-3-3 31 <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r. /V �� f } <br /> " vt e-00A CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address 1 of A/ ' <br /> 5 City <br /> Contractor's Name � License #/, hone ) 2Z;P1, <br /> TYPE OF WORK (Check.) : "NEW WELL / DEEPEN /, /f RECONDITION DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <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 <br /> ' Other Other Information <br /> 4 <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> k <br /> PUMP REPLACEMENT: / / State Work. Done <br /> PUMP REPAIR: / State Work Done p <br /> ESTRUCTION OF WELL: Well Diameter <br /> -- • •, _ Approximate Depth <br /> ' Describe. Material and Procedure <br /> - <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 ell, 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 o ...M kn wledge atd belief. <br /> SIGNED ITLE C � <br /> `(D W P PLAN ON 1E'VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PEASE II GROUT INSPECTION PHASE IL I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTIONB _. DATE 7 g 9 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE TION. <br /> E H 1426 1W 7/72 1M" <br />