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Sr JOAQUIN LOCAL HEALTH DISTRICT <br /> jj <br /> OR OFFICE USE: 1601 Hazelton Ave. , Stockton, Cal <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 1.710 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ,plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> id/or install the work herein described. This application is made in compliance with San Joaquin, <br /> )unty Ordinance No. 1862 and the Rules and Regulations of the San Jo a uin Local Health District. { <br /> sg ADDRESS/LOCATIONU } - CENSUS TRACT <br /> --A1'Z4!F-92 t4l- <br /> 4 <br /> ,per's Name '.. - Phon3 r��S�� •_ <br /> - q <br /> [dress Z ZE2 a City -- -- <br /> )ntractor's Name LicensejJ�/� <br /> !PE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / P REPAIR / / P RE C NT <br /> Other <br /> [STANCE TO -NEAREST: SEPTIC T SEWER L S PIT PRIVY <br /> SEWAGE DI OSAL 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 <br /> Domestic/public Driven Gauge of Casing Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> JMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 7MP REPLACEMENT: / / State Work Done <br /> UMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ad the State ,of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> iter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. <br /> IGNED :• ' <br /> TITLE, <br /> (DRAW PLOT PLAN ON REVERSE SI E <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I ` <br /> XPLICATION ACCEPTED BY DATE <br /> ,DDITIONAL COMMENTS <br /> PHASE II GROUT 11TSPECTION PHASE III FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE -' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />