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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. Hazelton ,Ave:A, 'Stockton, Calif. <br /> Telephone'-"' (209) '466-6781 <br /> APPLICATION FOR..WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIV PERMIT='EXPIRES 'i`YEAR FROM DATE ISSUED ' 'Da`te' `Issued <br /> r f (Complete',In' Triplicate) <br /> Application is' _hereby=mad'e° to°the: San !Joaquin Local 'Health District for 'a'permi't 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'`Ru1es arid' Regulations of the Sart Joaquin Local Health District <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name"- s # <br /> _ .> - Phone - <br /> Address <br /> City <br /> Contractor's Name , <br /> ` License 46 Phone��. /41 <br /> TYPE OF WORK (Check) :- NEW WELL /DEEPEN /? RECONDITION , DESTRUCTION <br /> 1' PUMP -INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> R <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER oS1t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIATIONS aro <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 XGravel Pack . Depth of Grout Seal <br /> Other L' Rotary Type of Grout <br /> Other Other Information d a <br /> PUMP INSTALLATION: Contractor 3 J/j11r <br /> Type, of Pump ,UJAH.P. <br /> PUMP REPLACEMENT: <br /> 5tate Work one <br /> PUMP REPAIR: - State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. Approximate Depth ' <br /> Describe Material and Procedure <br /> I hereby agree to complywith all laws and regulations of the ;an 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 tinew 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 f my knowl dge and belief. . <br /> SIGNED ✓ /� OE <br /> TITLE _�pDRAW PLOT PLAN ON REVERSE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ,. . <br /> APPLICATION ACCEPTED BY Ylr� V DATE61 73 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT .INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE �-r �7 INSPECTION BY DAT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE TION � <br /> E H 1426 7/72 1M ' <br />