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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR---''OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � ,ate <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7Z <br /> I (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 � <br /> �� V CENSUS TRACT <br /> Owner's Name ¢ar�• <br /> Phone <br /> E Address 3S`�(� <br /> City <br /> Contractor's Na <br /> License #�� Ione fr <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /_/ RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /? <br /> Other l/ / <br /> : . <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 <br /> _ Industrial Cable Tool Dia, of Well Excavation <br /> - Domestic/private ' Drilled Dia. of Well Casing V <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depthof Grout Seal <br /> Other <br /> I Rotary Type of Grout m <br /> ! Other Other Information E <br /> PUMP INSTALLATION: Contra,for <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / Slate Work Done ' <br />,DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> f <br /> i <br /> I hereby agree to comply withiall 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 true to the best of my knowledge a 0b ef. <br /> SIGNED <br /> (DRAW P PLAN ON REVER SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECfiION PHAS III FINAL INSPECTION <br /> INSPECTION BY ` DATE INSPECTION BY DATE d2 Z <br /> CALL FOR A GROUT INSPECTION PR19R TO GROUTING AND FINAL INSPECT �N. <br /> E H 14,26�i w g/�i� � �c �J*�` in su..,�,�- 7 3 <br /> wjr �e na t in Cr,W., f is L1< Szo v 7/72 1M <br />