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a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3-a% p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (-1-7 73(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 /> JOB ADDRESS/LOCATION { <br /> CENSUS TRACT /(o 2_—[so 2_ <br /> Owner's Name _ <br /> Phone. <br /> Address _ <br /> City .� <br /> Contractor's Name <br /> > License # Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /? RECONDITION /? DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / T <br /> Other J / — .,)�, <br /> -•C <br /> DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL "T <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> ----- Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel PackDepth of Grout Seal <br /> Other Rotary Type of Grout ' <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT' /r State Work Done <br /> PUMP REPAIR, /% State Work Done <br /> ESTRUCTION OF F WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San <br /> Joaquin Loc <br /> al <br /> Health Distri <br /> ctand the State -of California pertaining to or regulatingwell construction. Within FIFTEEN DAYSafter completion of my work on a new well, <br /> I will furnish the San Joaquin <br /> Local <br /> WELL DRILLERS REPORT of the well and notify them before putting the well inuse.HeThe haboverict a <br /> inf ormation. is true to the best of my knowledge and belief. <br /> SIGNED <br /> TC i TITLE <br /> �� (D W PLOT Oil REVERSE 5IDE <br /> PHASE IF <br /> OR DEPARTMENT USE ONLY 1 <br /> APPLICATION ACCEPTED BY DATE b- J <br /> ADDITIONAL COMMENTS: <br /> P E I GROUT INSPECTION <br /> PHASE FIN INSPECTI N <br /> DATE _INSPECTION !Y IM <br /> BY <br /> DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7172 1M <br />