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SAN JOAQUIN I&Al; jEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: _(209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t (Complete In Triplicate) 2ys,- (0;-,o --30 <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 and1the Rules and Regulations of the San Joaquin Local Health District. <br /> f j x.2.. .2 <br /> JOB ADDRESS/LOCATION - -CENSUS TRACT <br /> Owner's Name <br /> Phone "T_ <br /> AddressQ_ _ J ��/ �(f 7 y City ` <br /> Contractor's Name � License U <br /> %,Tv PPhone _a8==7J yd <br /> _ v ' <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_� RECONDITION /-7 DESTRUCTION /� `p <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 1°q <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � <br /> INTENDED USE TYPE OF WELL / CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing -V <br /> Domestic/public Driven Gauge of Casing k, .�.w <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> Other Other Information -1 , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / Sate Work Done <br /> PUMP REPAIR: / J State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth j <br /> Describe Material and Procedure I <br /> i <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 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 <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY __ f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 4ROUT INSPECTION PHASE III FleAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -^2 ?, <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. jz <br /> E H 1426 7/72 IM `e1J <br />