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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave,. , Stockton, Calif. <br /> Telephone: (209) •466-6781 <br /> APPLICATION FOR WELL...CONSTRUG'TION OR PUMP PERMIT Permit No. _L4Lt.� � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date .Issued <br /> (Complete In Triplicate) . ®�( _10- <br /> "41tf�' i <br /> Application is hereby made to -the, San Joaquin Local Health District. for. a permito construct <br /> and/or install the work-"herein described. This application is made in coinpliance with San Joaquin <br /> County Ordinance No.. 1862 and the Rules, and Regulations of •the San,Joaquin Local .Health District. <br /> JOB ADDRESS/LOCAT S ,U 'CENSUS' TRACT c5 � <br /> Owner's Name ; Phone <br /> AddressCity. <br /> Contractor's Name _ license <br /> TYPE OF WORK (Check) : NEW WELL /` / DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP INST TION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other J , <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LI ES PIT PRIVY (l� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPF OF WELL CONSTRUCTION SPECIFICAT EONSIndustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing g'Domestic/public Driven Gauge of Casing _— <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout p <br /> Other Other Information <br />" PUMP INSTALLATION: Contractor <br /> Type of .Pump H.P. <br /> PUMP REPLACEMENT. / / State Work Done , <br />' PUMP REPAIR: / :/ State Work Done <br /> AESTRUCTION ._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 ww and notify them before putting the well in use. The above <br /> information t e to the t o myn knowledge and belief. <br />, SIGNED TITLE <br /> / wMW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY J%mer/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - r 9 <br /> CALL FOR A GROUT INSPECTION.PRIOR -TO GROUTING AND FINAL INSPECTION. ? <br /> E H 1426 7/72 1M <br />