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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE; USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. . 34(-Rw <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X13--7s- <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. � <br /> . i <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name M )ZO -*I' /zm Phone <br /> Address City n .� , <br /> Contractor's Name WOODS LicensePhone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / tECONDITION_/_/ DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR/ / PUMP REPLACEMENT /7 {� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOA5 L FIELD CESSPOOL/SEEPAGE PIT OTHER �! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable 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 />` W OODS - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> F PUMP REPAIR: /_�- State -Work Done <br />' ,DFI�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> f . Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District i <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 /> 3 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 /> SIGNED , TITLE - <br />'> (DRAW PLOT PLAN ON REVERSE SIDE) - f <br /> FOR DEPARTMENT T <br /> _AE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY 00 DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPLrCTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ( y <br /> ' E H 1426 i 5/73111 - <br />