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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FOR OFFICE USE* 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) •466r-6781 <br /> APPLICATION FOR WELL. CONSTRUt,''TION OR PUMP PERMIT Permit No. <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; : Date' ,Issued ,, <br /> (-Complete In Triplicate) .: c�q / 0� st <br /> ,Application is hereby made• to•the5an• Joaquin Local Health District.fot.:a e?a 'fa conruct <br /> and/or install the work,�herein described. This application' i's made 'in c6inpliance•with San Joaquin <br /> County Ordinance' No., 1862 and the Rules, and Regulations of 'the San,Joaquin Loehl :Health District. <br /> JOB ADDRE55/LOCAT 4-CENSUS' TRA'C,"I' tS�1 <br /> t <br /> owner's Name ' ,.. 'a �.- , . • , '� . <br /> "Phone <br /> 'Address <br /> Contractor's Name _. -icense �!�? Phon <br /> 'TYPE OF WORK (Check): NEW WELL /` / DEEPEN /_/ RECONDITION /-7 DESTRUCTION //-7 <br /> PUMP INST TION / / PUMP REPAIR /—/—PUMP REPLACEMENT /-7 <br /> ' Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES PIT PRIVY fCq <br /> SEWAGE DISPOSAL FIELD / CESSPOOL/SEEPAGE PIT OTHER <br /> Y INTENDED USE TYPF, OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _Domestic/public _r Driven Gauge of Casing ,;L <br /> Xrrigation Gravel Pack Depth of Grout Seal <br /> Other RvL aiy Type of diouL <br /> Other Other Information <br /> ,PURR' INSTALLATION: Contractor <br /> Type of .Pump H.P. <br /> PUMP REPLACEMENT: / '/' S tate Work Done <br /> PUMP REPAIR., <br /> / :/ State Work Done <br /> �ESTRUCTION .OF WELL® Well Diameter Approximate Depth <br /> 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 Statee -of Califoyn:ia 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 Distridt a <br /> WELL DRILLERS REPORT of the w 1 and notify them before putting the well in use. The above <br /> 'information tr a to the • t o mynknowledge and belief, <br /> SIGNED //). TITLE <br /> W PLOT PLAN ON REVERSE SIDA­ — <br /> FOR <br /> DEPARTMENT USE ONLY <br /> PHASE - <br /> APPLICATION ACCEPTED BY . DATE "70 <br /> 'ADDITIONAL COMMENTS: E <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 1 INSPECTION BY , DATE °. INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION.PRIOR..TO GROUTING AND FINAL INSPECTION. <br /> ' <br /> 9 H 1426 7/72 1M� <br />