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M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone*: (209) 466-6781 <br /> JN. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ �7C ys <br /> !y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �3 <br /> (Complete In Triplicate) <br /> Application is hereby made' to the San Joaquin Local Health District for a permit to construct <br /> and/or. i.nstall 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%I.(3CAT10N � e�y.Q � LjENSUS TRACT <br /> Owner' �� Name <br /> Phone <br /> Address <br /> 5 2~ CAW City <br /> Contractor s Name License # 1 Z�. Phone <br /> TYPE OF WORK (Check) : NEW WELL / l- DEEPEN /_/ RECONDITION / / DESTRUCTION -7 <br /> PUMP INSTALLATION / / PUMP REPAIR / —PUMP 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 <br /> Industrial F! --- -- Cable Tool Dia,. of Well Excavation , <br /> Domestic/private Drilled Dia. of Well Casing <br /> W/ <br /> Domestic ublic �! <br /> F /p Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of .Grout <br /> Other Other Inf ormation , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 1� r <br /> PUMP REPLACEMENT: / / State Work Done . <br /> PUMP REPAIR:- State-Work Done + w - - - -�•. �---- <br /> ESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure J <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health .Distriet <br /> and thel 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 and belief. <br /> 'i. <br /> SIGNED <br /> TITLE <br /> !E (DRAW PLOT PLAN ON REVERSE SIDE _ <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I! <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS, lr <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALIAF'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H1426 7/72 1M <br />