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�a <br /> f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> V-PPLICATION .FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued X - 1, 7L <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 / r CENSUS TRACT <br /> Owner.'s Name Phone '-3��Cj^�.�jr' 1 <br /> Address _ City <br /> Con tractor's Name ' License Phone,'-3 Ld!2 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION /? DESTRUCTION /—T <br /> PUMP INSTALLATION/ / PUMP REPAIR FUMP REPLACEMENT /7 <br /> j Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t 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 'J <br /> D!ST Irrigation - - Gravel Pack "Depthof Grout Seal <br /> Other Rotary Type of Grout <br /> i Other Other Information <br /> PUMP INSTALLATION% Contractor <br /> Type of Pump H.P. C <br /> C <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> f <br /> ,DESTRUCTION 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 <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 /> u <br /> f SIGNEDTITLE <br /> (DRAW MM 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 PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE CL.2_,T' rdo� <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E.H 1426 4/72 1M <br />