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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave:,- Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7, 2-. ?'1 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedj-- 1j--7z,- <br /> z,- <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 % J� CENSUS TRACT <br /> Owner's Name 3V5 Phone <br /> Address 3� City <br /> Contractor's Name �"'� ;= o of License # Phonia , p,j C <br /> TYPE OF WORK (Check) :' NEW WELL DEEPEN /-7' RECONDITION /-7 - DESTRUCTION /-7- <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing .Q <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal CJ <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> n . <br /> PUMP INSTALLATION: Contractorc�e,c� ` <br /> Type of Pump H.P. s <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> ,PESTRUCTTON 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 G <br /> information is true t the best of my knowledge and belief. Y <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE2,,__ <br /> PHASE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. } <br /> E H 1426 4/72 1M <br /> f <br />