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SAN JOAQUIN LOCAL HEALTH DISTRICT A <br /> F'OR _vTS USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> A101CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued % <br /> k (Complete ,.In Triplicate)'. <br /> Application is here made to the San Joaquin Local Health• Dis.trict.: for•-A petmit` to construct <br /> and/or install the work herein-described. This application„-is made ini6 with Safi Joaquin, <br /> County Ordinance -No. 1862 and the Rules and Regula tions..of the .San Joaquin"Isocal Health District. <br /> JOB ADDRESS/LOCATION , = ;f CENSUS TRACT <br /> Owner's Name Phone <br /> T <br /> Address .- eo Q -City-_. A : <br /> Contractors Name a License Phone <br /> J <br /> .h <br /> TYPE.OF WORK (Check): NEW WELL DEEPEN. /. RECONDITION /_� DESTRUCTIONS/? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> o <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �3 ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 7 <br /> INTENDED USE TYPE OF WELL•. CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing /eL <br /> Domestic/public . Driven Gauge of Casing 4, <br /> -_ Irrigation Gravel Pack Depth of Grout Seal <br /> OtherRotary Type of Grout <br /> Other Other Information 4 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 7s <br /> PUMP REPLACEMENT: / / State Work Done <br /> I� <br /> PUMP REPAIR: / / State'Work Done <br />;.DESTRUCTION OF WELL: Well -Diameter - Approximate Depth <br /> r <br /> Describe Material and Procedure <br /> F <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 /> Fafter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> iWELL 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 /> t <br />' SIGNED TITLE I� <br /> (DRAW PLOT PLAN ON REVERSE SIDEY_ <br />} FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> COMMENTS: ; <br /> PHASE II ROUT INSPECTI N PHASE IIIIFINAL INSPECTION) <br /> INSPECTION BY DATE -7,W----INSPECTION BY DATE <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. A. <br /> E H 1426 7/72 1M , <br />