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`� J JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601: E. Hazelton Ave. , Stockton, Calif. ZD <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PU1U' PE i it N 70 h' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate Issued 2 7 <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 andthe Rules gut i sof the San Joaquin Local Health District. <br /> a W <br /> JOB ADDRESS/LOCATION - , y 7yi .t Gu. � i�, CENSUS TRACT <br /> Owner'e Name Phone <br /> Address L)_ ��- City <br /> Contractor's Name � � License #&)t.373 Phone3 (-O-ff3�- <br /> TYPE-OF WORK (Check): NEW WELL /-7 -DEEPEN /% REr_ONDIT ON%7' DMkUCTION 17 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER e� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS )� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled- Dia. 'of Well Casing t,� 4 o <br /> Domestic/public Driven Gauge of Casing _ O <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information , <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ! <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /3? State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <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 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE • <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M r,�,� <br />