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• x <br /> C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 46676781 <br /> APPLICATION FOR WELL, CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � � , <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 . CENSUS TRACT <br /> Owner's Name !A Phone 7 <br /> Address _ City -- ' <br /> Contractor's Naame �� License It/ 'Z Phone3 6�4-3� <br /> -Y <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /� RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATIONPUMP REPAIR PUMP REPLACEMENT 1-7 <br /> Other / / <br /> ,4 1 <br /> DISTANCE"TO NEAREST: SEPTIC TANK- SEWER 11NES PIT PRIVY { <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT r. OTHER <br /> `�k <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation r <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven \Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal`' -' <br /> 3 <br /> Other Rotary Type,of Grout " <br /> Other _ Other Information i, L� <br /> , <br /> PUMP INSTALLATION Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done 4 <br /> PUMP REPAIR: 4Ld-t State Work Done <br /> ,RESTRUCTION 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 State of California pertaining to or regulating well construction. Within FIFTEEN DAYS r <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 i <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 /> i <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 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 IM <br />