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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' F0 OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. 3 <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 /> JOB ADDRESS/LOCATION ® --4 .�e�� CENSUS TRACT �I <br /> Owner°s Mame Phone. zC� <br /> Q <br /> Address ��-_-- a` City -�✓ <br /> w <br /> Cantractorr°s Name - License # Phone <br /> ' TYPE OF WORK (Check)-. NEW WELL /% DEEPEN /� RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION /� PUFZP REPAIR /% PUMP REPLACEMENT <br /> ' Othe / & T <br /> D7IS`IANCE TO NEAREST-. SEPTIC TANK SEWER LINES PIT PRI <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE, TYPE OF WELL CONSTRUCTION SPECIFICATIONS a <br /> _ Industrial Cable Tool Dia. -of Well Excavation It. <br /> ' <br /> Domestic/private Drilled Dia. of Well Casing Nj <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout'Seal <br /> Other Rntnry Tyne of Grout <br /> O <br /> Other <br /> Other Information <br /> ' PUMP INSTALLATION: Contractor <br /> Type o u ' H.P, "2_.. <br /> PUMP REPLACEMENT. / State Work Done � <br /> ' PUMP REPAILR-. / / State Work Done <br /> DESTRUCTION OF WELL-. <br /> Well Diameter ®al Ap noxi atepth ' 12 <br /> t �, Q Describe terial and Pr cedure i <br /> 14 AJ4 <br /> Ihereby agree to comply with all laws regulations of the S n Joaquin al Health District <br /> ' and the State of California pertaining to or regulating well construction° Within FIFTEEN DAIS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distaidt 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 �C <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �° � _ DATE <br /> ' ADDITIONAL COMMNTS. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE ®�� <br /> CALL FOR A GROUT INSPECTION PRIOR TO OUTING AND INAL NSPECTIO <br /> E.H 1426 7/72 IM Ar <br />